PCIP CPD Registration Form

Registration Form
Welcome to the student intake form for our Continuous Professional Development (CPD) courses
Introduction to Gazespotting Online CPDIntroduction to The Nine Dimensions of Integration Psychotherapy
Pilamaya NewsletterThe Yogologist NewsletterSocial MediaOnline SearchMinded Institute MarketingOther

Student Information

Please be aware that all of the information you provide below will be encrypted and securely stored. Please contact us if you have any questions or concerns about how we store and protect your personal data in accordance with UK GDPR and ICO guidelines.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Phone Number
EmailTelephoneSMS/Text

Background & Personal History

The following questions are intended to help us understand more about your background and relevant personal history. Your responses help to inform us of how we might best be able to support your journey through our course.
YesNoUnsure
Please describe any previous training that may be relevant to your application...
Have you been diagnosed with a mental health or neurodevelopmental condition?
Is there anything else in your background or personal history you would like to share?
How does it feel to be you at this time?

Starting Point

Please take some time to reflect on your starting point. We want to know where you are in life, what are you bringing to the group and what you hope to take away.
Why do you feel drawn to this training?
What are you most looking forward to on this course?
Payment

Click the links below to pay via Stripe
CPD Standard Rate £300

CPD Early Bird £255

CPD Graduate Discount £240
Payment can also be made by bank transfer to:

The Pilamaya Centre Ltd

Account Number: 43373199

Sort Code: 60-83-71

Please reference CPD (date)
Certify & Submit
Applicant's Name*

First NameLast Name
By signing below, I certify that the information I have provided above is true to the best of my knowledge without any malice, negligence, or any intent to commit acts of misrepresentation. I am also aware that any intentionally false, misleading, or deceptive information provided may result in the automatic refusal of my application or subsequent withdrawal from the course, without recourse to a refund of monies paid towards my course fees.
Signature
Date Signed*

MonthDayYear
Date
Should be Empty:

Registration Form