CPM/CCP Registration

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 the primary email address you have provided 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.

If approved, your details will also be forwarded to the CPRB to begin processing your Annual Practicing Certificate. Once you have received your SCT membership certificate, you will need to complete an application as per the process at the following link. To start your registration application click "Login" and create an account. You will not need to send proof of your CPM/CCP enrollment and a signed declaration from your clinical supervisor, as this has already been provided by SCT.

Please email education.sct@gmail.com with any questions related to this form.

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

Date

Phone Number

Please enter your work email, if you have been provided with one, as your primary email. If not, please enter your personal email as both the primary and secondary email at this stage of the application. A work email will be required for the online learning system, and this will be requested once the application process is complete.

Primary Email

Secondary 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

City

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.

Job Title

Name of Department

Hospital

District

Country

Start Date of Current Position

Date

Weekly Hours

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.

Please select the relevant option;

Years of Experience

Professional Qualification

Other

What year was this qualification achieved?

Which module are you applying for?

Please upload your CV, including all procedures you currently perform;

Please describe your role, and why ECG interpretation is required;

Invoice Options;

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. If you are selecting "Invoice to employer", the invoice will be sent to the Charge Physiologist you have entered in the course supervision section.

Payment Options

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

Have you completed any NZQA approved qualifications (including schooling) in NZ in the past?

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, please use this link, and use the chatbot to find your number.

If you have an NSN, you are required to find it prior to submission of the form.

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?

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?

Supporting Hospital

Secondary Supervisor's Name

First NameLast Name

Secondary Supervisor's Email

example@example.com

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

Course Application Form

Personal Details

Employment Details

Course Selection & Payment

NZQA Details

Course Supervision

Declaration