AMAC Part 1 Course Registration Form

AMAC Part 1 Course Registration Form
Personal Details
Name*

First NameLast Name
Preferred name*
Date of Birth*

DayMonthYear
Date
MaleFemalePrefer not to specify
Nationality*
Country of Birth*
AboriginalTorres Strait IslanderMaoriNot applicable
VegetarianVeganHalalGluten FreeNo special requirementOther
Contact Details
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile phone number*
Preferred number for contact
Email*
Please Note: This email address will be shared with other AMAC Students and Staff
Photo ID

Please upload a photo ID - Driver's Licence or Passport
Photo ID*

Drivers Licence or Passport
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Course Pre-requisites:
Please read the course prerequisites in the AMAC website.

Medical practitioners MUST be able to tick requirements 1, 3, 4, 5 and 6.

Dentists MUST be able to tick requirements 2, 5 and 6.
1. I have completed a medical degree course (e.g. MBBS, MD, MBCHB, BMed)2. I have completed an undergraduate and/or postgraduate dental degree course (e.g. BDSC)3. I have completed a medical specialist training program (e.g. FRACGP, FARGP, FACRRM, FRACP)4. I am a vocationally registered GP5. I am currently practicing in my chosen medical/dental specialty6. I have access to my own patients (either in private practice or in hospital clinic) for using my acquired medical acupuncture skills
YesNo
AHPRA Number*
QI&CPD
ACRRMRACGPOther
What is your QI&CPD number?*
Type each college and the number: e.g. RACGP 123456
Acupuncture Experience
YesNo
Please state course name, institute name, and year/s attended.*
Please attach relevant certificate/s for your previous acupuncture studies.*

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How many years of acupuncture experience do you have?*
How many sessions (one session being 3-4hrs) per week do you practice acupuncture?*
Manual acupuncture using filiform needlesElectroacupunctureLaser acupunctureCuppingMoxibustionHerbs
What are your areas of interest in acupuncture?*
Professional CV

A brief outline of your medical and/or dental professional CV
Brief CV*

Please upload a brief medical professional CV
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Needling Consent

Please read this section carefully.
The AMAC Course will provide opportunities to experience the insertion of acupuncture needles, as well as to practise the insertion of needles into fellow students during the Face-to-Face workshops. This will be a great opportunity to develop and practise your needling skills and all students are encouraged to take part.

However, taking part in this process is not compulsory. You have a choice to participate, or not, in the process of both needling other students and being needled by other students, under teacher supervision during the workshops.

An important part of the decision to participate in needling is an understanding of possible adverse effects of acupuncture:
- drowsiness occurs after treatment in a small percentage of patients; if you experience this you are advised not to drive until this effect has passed;
- minor bleeding or bruising occurs after acupuncture in about 3% of treatments;
- pain during treatment occurs in about 1% of treatments and can last for a few days;
- soft tissue injury, tendon and nerve injury are rare and can last for a few days to few weeks;
- existing symptoms can get worse in 24-48 hours after treatment (less than 3% of patients), although this is usually a good sign that you have responded to treatment;
- fainting can occur in patients who receive needles for any reason including acupuncture, particularly at the first treatment.
It is also compulsory that you let your teachers know if you:
- have ever experienced a fit, faint or funny turn;
- have a pacemaker or any other electrical implants;
- have a bleeding disorder; or you are taking anti-coagulants or any other medication;
- have damaged heart valves or have any other particular risk of infection;
- have Hepatitis B, Hepatitis C, immunosuppression, HIV or other infectious disease;
- have any implants (joints or other);
- are pregnant;
- have a needle phobia;
- have a photosensitive disorder;
- have a significant pain condition or neurosensitisation
Single-use, sterile, disposable needles are always used in Australian medical practice and accordingly, during teaching sessions of the AMAC Course.
I consent to taking part in practising acupuncture needling. This includes having acupuncture needles inserted into me by myself, the other fully qualified and registered medical practitioners, enrolled students and authorized teachers for the AMAC Course. I understand that I can opt out at any time.I do not consent to taking part in practising acupuncture needling.
Signature*

Clear
Date*

DayMonthYear
Date you signed the needling consent
Enrolment Dates
Enrolment for the Part 1 Course
- Opens at 9am (AEST) 1 August 2024, and
- Closes at 5:30pm (ADST) 29 November 2024
Please Note: Enrolments will not be accepted outside these dates.

All registration documents and the course fee must be received in full to confirm enrolment.

Enrolments will not be accepted after 5.30pm(ADST) Friday 29 November 2024 under any circumstance.
Course Fee
Earlybird Rate $9,625 applies to enrolments received by 5:30pm(ADST) Thursday, 31 October 2024.

Standard Rate $10,600 applies to enrolments received after 5:30pm(ADST) Thursday, 31 October and before 5:30pm(ADST) Friday, 29 November 2024.
Electronic TransferCredit Card
Electronic Transfer:

Account Name: Australian Medical Acupuncture College
BSB: 084-484 Account No: 551553074
* Please use your full name as reference
Credit Card

For phone payments using your credit card, please contact Lisa Williams (PA to AMAC Treasurer) on 0428 850 771.

NB: email is not secure, do NOT sent credit card details by email.
Declaration of Understanding

Each applicant is required to read and sign the form below to acknowledge their understanding and agreement of the statements included in this declaration. The documents listed below should have been sent to you as separate pdfs together with the link to this form.
The Part 1 Course Curriculum and timetable have been made available to me.The Part 1 Course Assessment Guideline has been made available to me.I have read the AMAC Student Code of Conduct and the Student Misconduct Policy and understand my obligations and responsibilities as a student of AMAC.The Adverse Circumstance Policy and Procedure documents have been made available to me.
Signature*

Clear
Date*

DayMonthYear
The date you signed the Declaration of Understanding
Should be Empty:

AMAC Part 1 Course Registration Form

Personal Details

Contact Details

Photo ID

Course Pre-requisites:

QI&CPD

Acupuncture Experience

Professional CV

Needling Consent

Enrolment Dates

Course Fee

Declaration of Understanding