Experiential Course Registration Form

Experiential Course Registration Form
Una currently has no plans to run an experiential course but several people that Una has trained in the McCluskey Model are running such courses. Please only complete this registration form if you are happy for us to share your details with a trained member of the Association.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postcode
E-mail
Contact Number
Please include international dialling code and preferably provide a mobile number.
Qualifications
Governing Body (if registered)
e.g. IACP/UKCP, etc
How long qualified
My current work situation, roles and responsibilities
My training in individual, group or family therapy
My expectations of the course
How I expect to use what I learn from the experience
I heard about experiential courses

From a colleagueAt an event run by Una or a colleagueThrough an internet searchI have previously attended an experientialOther
I am aware that the course is predominantly experiential.

YesNo
I would be happy for you to share my details with someone who is trained in and using the McCluskey Model to run experiential courses.

YesNo
My preferred option for attending an experiential course would be

In PersonZoomEither
In line with the requirements of GDPR, I give express permission for you to keep my contact details on file and use them to notify me of future courses, workshops, conferences and publications of Una McCluskey.

YesNo
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