Application - Diagnostician - CAIP - Canadian Association of Irlen Professionals

CANADIAN ASSOCIATION OF IRLEN PROFESSIONALS
REQUEST FOR DIAGNOSTICIAN MEMBERSHIP

* Indicates required field

Name *

First

Last

Address *

Address 2 *

City *

Province *

Postal Code *

Date *

Phone Number (Primary) *

Phone Number (Cell) *

Phone Number (Office) *

Email *

Diagnostician (full membership only)

When were you certified by the Institute? mm/dd/yy *

Name of your supervising Clinic Director *

Indicate the average number of hours per month you spend as an Irlen Diagnostician *

By submitting this form, you agree that if admitted to CAIP, will you fully and completely abide by its Code of Ethics. Diagnostician membership fee: $100 per year

Agree & Submit

CANADIAN ASSOCIATION OF IRLEN PROFESSIONALSREQUEST FOR DIAGNOSTICIAN MEMBERSHIP

Diagnostician (full membership only)

CANADIAN ASSOCIATION OF IRLEN PROFESSIONALS
REQUEST FOR DIAGNOSTICIAN MEMBERSHIP