Dry Needling Course Application Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityCounty

Eircode

Phone Number*

Please enter a valid phone number. By providing my phone number I consent to IN.C.O.T. contacting me by phone or message.

Email*

By providing my email address, I consent to IN.C.O.T. sending me electronic communications.

Date of birth*

PPS Number*

Nationality*

Take Your Photo. We require a photo of applicants for our records.

To which gender identity do you most identify?*

Do you require special assistance during the course?*

YesNo

In the box below, please indicate the title of any previous therapy courses you have completed, start and end dates and the name of the education provider. If this is your first course type NIL.

I have completed a bank transfer to IN.C.O.T. for the amount of €500. PTSB Ballincollig BIC: IPBSIE2D IBAN: IE70IPBS99071530531083

Yes

I consent to IN.C.O.T. contacting any pearson to obtain further information about my application or to verify the information I have provided and agree that any person who is so contacted may provide IN.C.O.T. with any information about me which that person holds.
I confirm that the information I have provided in this application is correct and understand that fraudulently procuring acceptance for recognition of prior learning will result in my application being cancelled.
I consent to IN.C.O.T. having access to my personal data as supplied by me and I understand that this information will not be shared in any public forum. I consent to my information being kept on IN.C.O.T. database for the purpose of my application and course of study only.

I consent*

Yes

Signature*

Date*

Dry Needling Course

Additional courses completed

Payment

Declarations