FG MLD 1 & 2 Day Review

LTA Recertification Training Application Form

LTA Therapist's only
Training History
Are you an LTA Therapist? *
Do you know your Therapist number?
You can find this on your Certificate - Don't worry if you don't have it to hand!
When did you qualify as an LTA Therapist? *
An estimated Date & Year will be help us locate your details
When was the date of your last Review? (If applicable)
An estimated Date & Year will be help us locate your details
Personal Information
Name *

Prefix First Name Last Name
Date of Birth *

Day Month Year
Date
Home Address *

Street Address

Street Address Line 2

City County

Postal / Zip Country
Correspondence E-mail *

Confirmation Email Please note all correspondence will be sent here
Personal Contact Telephone Number *
This will be the number that we will need to contact you on for any reason
Emergency Contact Name and Relation *
Emergency Contact Number *
Personal Contact Telephone Number

Area Code Phone Number
Course Requirements
Type of Course Required *
Admin Note:

A 2 Day Review is required 12 months after successful completion of your initial training.

A 1 Day Review is required every 2 years following your 2 day review.

If you wish to be a member of MLD UK you need to complete a 1 Day Review + Bandaging assessment every 2 years.
Start Date Of Course *

Day Month Year
Payment Information
Who will fund the course?

SELF EMPLOYER
PERSONAL - If you are funding the course, please select how you would like to pay

INVOICE CREDIT / DEBIT
EMPLOYER - If your employer is funding the course, is a Purchase Order number required?

YES - please ensure this has been applied for before completing this application. NO
PO Number
Company Name
Email Address for Invoicing
This may be your finance or accounts department
Invoice Address

Street Address

Street Address Line 2

City County

Postal / Zip Code Country
Terms & Conditions
When submitting this application, you agree to the full Terms & Conditions that apply to this booking on our website: www.lymph.org.uk/terms-and-conditions *

I have read and understood the full T&C's
Declaration
I confirm that all the information supplied is correct, complete and accurate.

I understand that my application will be reviewed and will need to be clarified by LTA to ensure my eligibility to attend the course requested.

I am aware that LTA will process my personal data and hold on file for the duration of my certification with LTA, or for 7 years, whichever is longer and use my data for the purpose connected with my studies, health and safety and other categories of data collection outlined in the Privacy Notice and in line with the General Data Protection Regulations (GDPR)
I give my consent to the processing of my personal data within this context and that I have read and agree to the Terms of Declaration: *

Yes, please handle my data with care
For further information about how we collect and use your data, please see our Privacy Notice

http://www.lymph.org.uk/privacy-notice/
Once we have received your application, we will verify your booking and a member of our Admin Team will be in touch.
Should be Empty:

LTA Recertification Training Application Form

Training History

Personal Information

Course Requirements

Payment Information

Terms & Conditions

Declaration