Student Member to Associate Member Application for Graduate Students of University of Guelph and University of Winnipeg

Student Member to Associate Member Application for Graduate Students of University of Guelph and University of Winnipeg
Preferred Prefix:
Preferred Pro noun
Legal First Name
Preferred First Name:
Legal Last Name:
Email: This is the address CACFT will use to contact you and the one you should use when contacting them.
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Preferred Phone Number:
Are you planning on working towards becoming an RMFT (Registered Marriage and Family Therapist)?
What age range are you in?
Languages other than English spoken
Your CACFT membership #
What is your Masters Degree?
ETHICS: Has your registration, certification or license to practice in the health care industry ever been suspended, revoked, or denied, or has any other disciplinary action been taken against you by any provincial, federal or state, regulatory body or foreign jurisdiction, or are you presently under investigation by any regulatory body to the best of your knowledge?
Signature
If you are practicing in a regulated province please upload a document that shows you are a member of a regulatory body.

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All CACFT/ACTCF members are required to be in complaince with the regulatory laws of the jurisdiction(s) in which they practice. It is each member's responsibility to be aware of, and to ensure that they are practicing within the laws of the jurdisctions(s) in which they practice.
Plan for Completing Supervision Requirement
If you are currently working to complete your 1000 hour Direct Client Contact requirement, please identify where you intend to complete these hours. e.g agency, private practice
If you are currently working to complete your 200 hours of supervision, please complete the following plan:
Primary Supervisor: Name
Credentials
Contact Information for above supervisor
Secondary Supervisor Name
Credentials
Contact Information for the above supervisor
Please upload the CACFT Accredited Program Completion Attestation you received from your university.

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Please upload your transcript.

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Date of submitting this application to transfer to Associate member

MonthDayYear
Date
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