Wild Image Registration Form
Fill out the form carefully for registration
Applicant Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Website/social media/portfolio of work
Why are you interested in gaining facilitation skills in therapeutic photography? How will this help you personally? How will this support you to help others?
Have you done any other training that you feel may have given you skills you could draw on in this work? If yes, please list include them:
Are you currently working as a professional photographer?
Yes
No
If yes, how many years of experience do you have?
Under 1 year
1-3 years
3-5 years
5+ years
Are in intending to apply for one of the scholarships?
Yes
No
If yes, please explain why this scholarship would support you?
Do you agree that you have thoroughly read the information page and you understand the financial and time investment in this training?
Yes, I have read the relevant information and understand the fee and time investment involved.
Submit
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