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Post-Diploma Clinical Mentoring Programme
» Post-Diploma Clinical Mentoring Programme Application
In this section
Post-Diploma Clinical Mentoring Programme
Post-Diploma Clinical Mentoring Programme Application
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)
CANADA - Montreal (can also accommodate French speakers)
USA - Austin, Texas
USA - Cedar Grove, New Jersey
Preferred Clinical Venue (second choice)
CANADA - Montreal (can also accommodate French speakers)
USA - Austin, Texas
USA - Cedar Grove, New Jersey
Please outline your clinical environment:
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:
More Information
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