Application - Screeners - CAIP - Canadian Association of Irlen Professionals

CANADIAN ASSOCIATION OF IRLEN PROFESSIONALS
REQUEST FOR SCREENERS 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 *

Screeners (full membership only)

With access to all in-service training and listing on CAIP national registry.

Are you currently certified with the Irlen Institute? *

Yes No

When were you trained to be a screener? mm/dd/yy *

Trainer’s name? *

In what cities or areas do you offer your services? *

How many screenings have you done during the last 12 months? *

Do you normally refer screening clients to an Irlen Centre Director for Irlen Spectral Filters? *

Yes No

What % of your referrals to a diagnostician go for Irlen Spectral Filters? *

By submitting this form, you agree that if admitted to CAIP, will you fully and completely abide by its Code of Ethics. Screener membership fee: $50 per year

Agree & Submit

CANADIAN ASSOCIATION OF IRLEN PROFESSIONALSREQUEST FOR SCREENERS MEMBERSHIP

Screeners (full membership only)

CANADIAN ASSOCIATION OF IRLEN PROFESSIONALS
REQUEST FOR SCREENERS MEMBERSHIP