LOCATION : ......................................................
LOCATION : ......................................................
DATE PART I : ..................................................
DATE SUPERVISION I : .....................................
DATE PART II : .................................................
DATE SUPERVISION II : ....................................
MASTERCLASS EMDR CHILDREN
ADOLESCENTS...
REGISTR ATION FORM
π MRS π MR
NAME & FIRST NAME: ........................................................................................................................................
PROFESSION & TITLE: .......................................................................................................................................
POSTAL ADDRESS: ............................................................................................................................................
PHONE: ................................................................ MOBILE: .............................................................................
E-MAIL: ..............................................................................................................................................................
PLACE OF WORK: ..............................................................................................................................................
TYPE DβEXERCICE: π CABINET π INSTITUTION
π INDIVIDUAL TRAINING - INVOICE ADDRESS:
............................................................................................................................................................................
π CONTINUING TRAINING - ADDRESS OF THE ORGANIZATION TAKING CHARGE OF TRAINING:
............................................................................................................................................................................ RESPONSIBILITY FOR THE APPLICATION: .........................................................................................................
PHONE: .................................................................. E-MAIL: .............................................................................
INITIAL EMDR TRAINING:
LEVEL I : DATES : .............................................. EMDR EUROPE TRAINER: .......................................................
LEVEL II : DATES : ............................................. EMDR EUROPE TRAINER: .......................................................
EMDR EUROPE SUPERVISORS: ........................................................................................................................
ACCREDITATION DATE AND SUPERVISORβS NAME EMDR EUROPE: .................................................................
SEMINARS EMDR FOLLOWED IN CONTINUING TRAINING: ................................................................................
I, the undersigned, certify that I have read the information and conditions stipulated in the presentation of the course and wish to register with the MASTERCLASS children and adolescents
LOCATION : DATE : SIGNATURE :
This information is for the sole use of the French School of Psychotherapy EMDR. It may also be used by the EMDR France Association. If you would prefer not, check the box π
SEND YOUR REGISTRATION APPLICATION TO : EFPE - 00 XXX XXXXXXXX - XXXXXXXX X - 00000 TOULOUSE AS THE NUMBER OF PLACES ARE LIMITED, THE REGISTRATION WILL BE VALIDATED BY ORDER OF ARRIVAL OF THE COMPLETE APPLICATIONS.
YOUR REGISTRATION IS PROCESSED AFTER THE 10 LEGAL DAYS OF WITHDRAWAL, POSTMARK BEING TAKEN AS PROOF.
REGISTRATION APPLICATION COMPRISING OF:
π The registration form completed and signed
π A identity picture
π The payment (cheque made payable to : EMDR FORMATION)
EMDR FORMATION - EFPE
00 XXX XXXXXXXX - XXXXXXXX X - 00000 XXXXXXXX - 06 88 98 08 25 - MAIL : xxxx.xxxx@xxxxx.xxx - xxx.xxxx.xx
NΒ° SIRET : 814 870 598 00012 - NΒ° DE FORMATEUR : 11 75 54209 75