LCP Organizational Membership Registration Form

APPLICATION FOR ORGANIZATIONAL MEMBERSHIP

Please complete this form thoroughly and truthfully. For detailed information on the eligibility requirements for organizational membership, visit our official website at livencepsych.com. This form will be automatically received by the Center. Within this form, we will also be asking you to upload your organization's proof of business registration (DTI or SEC registration) or Mayor's permit along with the curriculum vitae or résumé of your Head of Office.
Organization Information
Organization Name*
Please input the name of the organization as registered in the government (e.g., DTI or SEC).
Type of Organization*
Phone Number*
E-mail*
example@gmail.com
Website (if applicable)*
Please type N/A if not applicable.
Address*

Street Address

Barangay

City/MunicipalityState / Province

Postal / Zip CodeCountry
Primary Contact Person Information
Name*

First NameMiddle Name (Optional)Last NameSuffix
Position/Designation*
Phone Number*
E-mail*
example@gmail.com
Membership Details
Membership Fee*

Organizational Membership (PHP 20,000.00)
Number of Designated Members*
Up to 5 members only.
Organizational Interests
Which areas of trauma-informed practice is your organization most interested in?

Trauma Assessment and ScreeningTrauma-Sensitive Communication and EngagementPsychoeducation on TraumaTrauma-Informed InterventionsVicarious Trauma and Traumatic Stress ManagementCultural Competency and Trauma-Informed CareResilience and Posttraumatic GrowthSafety Planning and Crisis InterventionTrauma-Informed SupervisionOrganizational/Workplace TraumaTrauma Advocacy and Systems Change
Document Uploads
Upload DTI/SEC Registration Certificate or Mayor's Permit*
Upload CV or résumé of your Head of Office*
Payment Details

Please note that all payments are NON-REFUNDABLE, BUT TRANSFERABLE.
Payment Method*

Bank Transfer via Metrobank (Account Name: Livence Psychological Services; Account No.: 313-3-31397966-1)GCash (Account Name: Ron Gabriel Peji; Account No.: 09754590712)Maya (Account Name: Ron Gabriel Peji; Account No.: 09754590712)
Upload Proof of Payment*
Acknowledgement and Consent
Agreement to Membership Guidelines and Policies*

In behalf of our organization, I, the primary contact person whose information appear herein, have read, understood, and agree to abide by the guidelines, policies, and terms of membership as set forth by Livence Center for Psychotraumatology. I acknowledge that failure to comply with these guidelines may result in the rejection, suspension, or termination of our membership.
Opt-in for Email Updates and Newsletters*

Yes, our organization would like to receive regular updates, newsletters, and announcements regarding upcoming events, workshops, and resources from Livence Center for Psychotraumatology.No, our organization does not wish to receive email updates and newsletters.
Certification of Information Accuracy*

In behalf of our organization, I hereby certify that all the information provided in this application is accurate and truthful to the best of my knowledge. I understand that providing false or misleading information may result in the rejection of my membership application or the termination of my membership.
Once you submit this form, Livence Center for Psychotraumatology will review your organization's application. Before reviewing this application form, please submit a copy of the curriculum vitae or résumé and updated formal headshot of each of your designated members. Once these documents are accomplished, please wait for approximately 5-7 working days for the decision of the Center that will be sent to you via email.

Thank you!
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APPLICATION FOR ORGANIZATIONAL MEMBERSHIP

Organization Information

Primary Contact Person Information

Membership Details

Organizational Interests

Document Uploads

Payment Details

Acknowledgement and Consent