CPM/CCP Registration

Course Application Form
Please email education.sct@gmail.com with any questions related to this form.
Personal Details
Name*

First NameLast Name
Preferred Name
Date of Birth*

DayMonthYear
Date
Phone Number*
Work Email*
Personal Email
Gender
Ethnicity
We collect ethnicity and gender data to report on diversity and the representativeness of our membership. Feel free to select multiple options, or "prefer not to answer" if this is the case.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employment Details
Job Title*
Name of Department
Hospital*
District*
Country*
Start Date of Current Position*

DayMonthYear
Date
Weekly Hours*
Are you a member of PiCSA?

YesNo
Course Selection & Payment
Please select the relevant option;*

Certificate in Physiological Measurement (CPM) - $1500Certification of Cardiac Physiologists (CCP, includes CPM) - $3000Certification of Cardiac Physiologists (without CPM) - $1500CCP in two installments of $1500 (includes CPM)Cardiac Physiology Technician Advance Practice ModulesBasic ECG Interpretation Course - $250
Years of Experience
Professional Qualification

CPMOther
What year was this qualification achieved?
Which module are you applying for?

Ambulatory Monitoring Analysis - $500
Please upload your CV, including all procedures you currently perform;

Cancelof
Please describe your role, and why ECG interpretation is required;
Payment Options;*

Invoice to applicantInvoice to employer
Managers Name

First NameLast Name
Managers Email
If you select 'invoice to employer', the invoice will be sent to the details you have entered as the Charge Physiologist in the employment information section. Pleasure ensure this has been discussed prior to submission.
Course Supervision
Your supervisor is the clinical educator that you will discuss your training with on a regular basis, and who will be responsible for the final approval of your course documents. This may need discussion with your charge physiologist/team leader/manager.
Supervisors Name*

First NameLast Name
Supervisors Title
Supervisors Email*
Current APC and CPRB Registration?*

YesNo
If your supervisor is not the Charge Physiologist at your hospital, please provide their details below;
Charge Physiologists Name

First NameLast Name
Charge Physiologists Title
Charge Physiologists Email
Declaration
- I declare that the statements I have made are accurate.
- I declare to be governed by the rules & regulations of the society and advance the objects of the Society.
- I agree to inform the society immediately of any change in circumstances which may affect my right to continue as a member of the society.
- I consent to be a Member of the Society.
- I agree to promptly advise the Society of any change to my name and/or contact details.
- I agree to my supervisor and charge physiologist/team leader/manager receiving information from SCT regarding my course progress and results.
Signature

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Course Application Form

Personal Details

Employment Details

Course Selection & Payment

Course Supervision

Declaration