CPM/CCP Registration

Course Application Form
Please ask your supervisor/team leader to check over the form prior to submission to ensure everything is correct. Once digitally signed, forms cannot be edited, so any errors will require a full re-submission.

When you are accepted for the course, an email will be sent to you with a Memorandum of Understanding to sign. Please complete this as soon as possible.

Once your supervisor and SCT have signed this form, you will be sent a username and password for accessing the online learning site.

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

First NameMiddle NameLast Name
Please enter your legal name, as this is what will be displayed on your completion certificate.
Preferred Name
Date of Birth*

DayMonthYear
Date
Phone Number*
Primary Email*
Secondary Email
Please enter your work email if you have been provided with one. If not, use your personal email at this stage of the application. A work email will be required for the online learning system - further instructions will be in your submission receipt 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
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please note this will only be used in the case of a medical or mental health event.
Do you have any medical conditions that the SCT need to be aware of?
This is to help us provide appropriate information & training, or put plans in place to support your learning.
Employment Details
Job Title*
Job Title
Name of Department
Hospital*
District*
Country*
Start Date of Current Position*

DayMonthYear
Date
Weekly Hours*
Course Selection & Payment
Please select the relevant option;*

Diploma in Cardiac Physiological Measurement (CPM) - $1500Certification of Cardiac Physiologists (CCP, includes CPM) - $3000Certification of Cardiac Physiologists (without CPM) - $1500
If you have been employed as a Trainee or Provisional Cardiac / Physiology Technician;

The training course you will be completing over the next year is called the “Diploma in Cardiac in Physiological Measurement” (CPM).

If you have been employed as a Trainee or Provisional Cardiac Physiologist;

The training course you will be completing over the next year is called the “Certification of Cardiac Physiologists” (CCP). You should select the option that says (CCP, includes CPM). You will be automatically enrolled in the CPM course as well.

Please only select “Certification of Cardiac Physiologists (without CPM)” if you have previously completed CPM.
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;
Invoice Options;*

Invoice to applicantInvoice to employer
Please check with your supervisor, department team leader, or manager whether the hospital will pay your fees directly or whether you need to pay and then get reimbursed.
Payment Options*

Total cost upfrontCPM/CCP in two installments of $1500
If you have elected to receive the invoice and the course fees are >$500, you will be invoiced an initial $500, then the remainder after the 2-month fee refund period.
Manager's Name

First NameLast Name
Manager's Email
The invoice will be sent to the Charge Physiologist you have entered in the course supervision section. Please ensure this has been discussed prior to submission.
NZQA Details
Have you completed any NZQA approved qualifications (including schooling) in NZ in the past?*

YesNo
National Student Number*
If you do not have an NSN, SCT will apply for you to be allocated one.

If you are unsure of your NSN, instructions to find it can be found here. If you have an NSN, you are required to find it prior to submission of the form.
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.
Supervisor's Name*

First NameLast Name
Supervisor's Job Title
Supervisor's Email*
Current APC and CPRB Registration?*

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

First NameLast Name
Charge Physiologist's Job Title
Charge Physiologist's Email
Will your training be supported by another hospital?

YesNo
Secondary Supervisor's Name

First NameLast Name
Secondary Supervisor's Email
example@example.com
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.
- I have read and understand the fee refund policy.
Signature

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Course Application Form

Personal Details

Employment Details

Course Selection & Payment

NZQA Details

Course Supervision

Declaration