Chinese Herbal Medicine Diploma Registration Form Year 1

Chinese Herbal Medicine Diploma

Registration Form - Year 1 - 24/25 Cohort (Page 1)
Student Name*

First NameLast Name
Email Address*
All student correspondence will be sent here
Mobile Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is your nationality?*
Please enter your nationality
Ethnicity
Occupation*
Please enter your current/most recent occupation

Chinese Herbal Medicine Diploma

Registration Form - 23/24 Cohort (Page 2)
Highest Level of Formal Education*

Bachelor's degreeMaster's degreeDoctorate/PhDOther
If other, please state your formal education below:
Languages Spoken*
Do you have English at GCSE grade C or above? *
Do you have English level at ILTES at 6.0 if English is not your first language? *
Do you hold a professional status / licence in healthcare practice and practise some form of Chinese Medicine eg acupuncture? If so, please give details. *
Please write "none" if not applicable
Do you belong to any professional regulatory bodies? If so, please give details.*
Please write "none" if not applicable
Have you completed a relevant accredited foundation course? Please give details of the course, course provider, qualifications gained and date of completion. *
Please write "none" if not applicable
Have you completed a course / module of Chinese medicine theory of 60 hours learning at level 4 or above? If so, please give details. *
Please write "none" if not applicable
Have you practiced healthcare therapy directly facing patients (for example, acupuncture for at least 400 hours, including that under supervision)? If so, please give details. *
Please write "none" if not applicable
Can you provide a reference from a professional, academic or line manager? *
Please write "none" if not applicable
Are you subject to disciplinary action? Have you got unsolved complaints over your professional practice? *
Please write "none" if not applicable
Do you have any special educational needs or disability which may affect your ability to complete this course? If so, please give details. *
Please write "none" if not applicable
Do you prefer to pay in full or in instalments? *
Please write "none" if not applicable
What do you hope to achieve by applying to enrol on this diploma?*
DECLARATION/LEARNING AGREEMENT

As accepted onto the course, I fully understand that the learning course is incorporated with the practice of Chinese herbal medicine, which requires compliance with professional regulations and Government rules.
I confirm that I have access to a computer, sufficient internet connection at home, and IT and writing skills necessary for online teaching and learning.
I declare that the information I provided in this form is true and will inform the Academy at the earliest possible chance.
Tick to confirm to the above agreement*

I confirm
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