Post-Diploma Clinical Mentoring Programme Application

First Name

Last Name

Credentials

Date of Birth

Address

Phone (W)

Phone (H)

Phone (Mobile)

Email

Profession

Nationality

Year of your Diploma and Clinical Venue

Please list any medical conditions or disabilities that may affect your participation in the Post-Diploma Clinical Mentoring Programme

Preferred Clinical Venue (first choice)

Preferred Clinical Venue (second choice)

Spinal vs extremity ratio:

Predominant type of patients e.g., athletes, elderly etc:

Clinical specialism e.g. headaches, TMJ, post-trauma etc:

Other clinical environment comments:

Reasons for applying to participate in the Post-Diploma Clinical Mentoring Programme:

Personal goals I would want to achieve in Post-Diploma Clinical Mentoring Programme:

Please attach a copy of your Diploma certificate (photo is fine)

Please upload your Full Curriculum Vitae