In order to apply for a membership in Alberta Reflexology and Acupressure Society, please complete all requested information and return it with payment. The latest date for yearly renewal is 31.12.

Please print legibly and include your certificates of graduation or course completion!

Membership fee:

25 CAD new member or 25 CAD renewal, please provide your membership # __________________________________

Last Name:______________________ First Name:___________________Initial:______________

Home Address:__________________________City________________ Province ________Postal Code_____________

Tel: ( )___________Fax:( )_______________E-mail:_____________________________________________________

Date of birth (MM/DD/YY) ___________________________ Gender: Male or Female

I am or will be reflexologists and/or acupressurists licensed by the City of _____________________________________

If you will be providing services in a municipality that requires you to have a practitioner’s license, you must have and maintain that licensing. Please provide License No. ______________________

Did you obtain or intend to obtain a signed consent or waiver from clients acknowledging disclosure of treatment limitations, contraindication and possible side effects of services to be provided?

YES or NO

Have you ever pleaded guilty or been convicted of a criminal offense for which you have not been pardoned? YES or NO, if yes, please provide details and also include a copy of a current criminal records check with City and Province of conviction:

_______________________________________________________________________________________________

Are you interested in volunteering your services to the Alberta Reflexology and Acupressure Society? YES or NO

I, the undersigned, declare that to the best of my knowledge the information provided and the statements made in this application and in any attached documents are true. I have read and agree with Alberta Reflexology and Acupressure Society (Society) Code of Ethics and I agree to abide by the bylaws of Society. I realize that any violation or misconduct of Society Code of Ethics will result in my expulsion from Society and all of my privileges associated with this organization will be revoked. I understand that Board Members of Society have no legal responsibilities for any my actions.

Practitioner Signature: ______________________________ Dated_________________________