APPLICATION FOR MEMBERSHIP FOR THE AAOMT
Registration form AAOMT Fees Full $500 Student $100
Please circle which membership you are applying for:
Full/Student/Supporting member (*see below for full descriptions)
Payments to be made to Alberta Association of Osteopathic Manual Therapists, and sent along with forms and proof of insurance to: 4 Manyhorses Bay, Redwood Meadows, Alberta T3Z 1A1.
The AAOMT membership year runs from August to August. If you are applying at a time other than August there will be monthly fee of $41.66 for full members and $20.83 for students. The month you apply in is included in this. For queries on this contact [email protected]
PERSONALDATA
Last name:______First name:______Middle initial:______Gender: M/F AAOMT no.:______Date of birth:______HOME ADDRESS: Email:______PRIMARY BUSINESS/CLINIC ADDRESS: Name: Clinic Name: ______Address: Address: ______Home Phone: ______Work/Clinic phone: Cell Phone: ______Fax: Website: ______
If you have other business addresses, please list them on the reverse of this page
*Full members: Must be a graduate of a Canadian or overseas Osteopathic college that is approved by AAOMT. This college must meet or exceed the benchmark guidelines for osteopathic education as outlined by the WHO benchmarks for education in Osteopathy 2010. For example to meet the requirements of Type 1 education the college must provide a minimum of 4 years full time (4200 hours) with at least 1000 hours clinical training for students with no prior training in healthcare. Type 2 courses cover the same competencies as type 1 and are for students with a prior qualification in health care. Typically they are 1000 hours over five years including supervised clinical training and a research component
Alberta Association of Osteopathic Manual Therapists APPLICATION FOR MEMBERSHIP FOR THE AAOMT
Student Membership: A student must be enrolled in an approved Canadian or Overseas Osteopathic College
General Questions
1. I can speak and/or write: English / French Please list all other languages you use in you office: ______
2. Do you currently carry Osteopathic Liability Insurance? Yes/ No If yes please provide a copy with your application
(NOTE: as of 2011, the Alberta Association of Osteopathic Manual Therapists will require a personal and professional liability of at least 2 million dollars)
3. Where did you receive your Osteopathic training? ______
Please provide a copy of your diploma or certificate
4. List all other health professions you are registered with in Alberta (e.g. College of Massage Therapists, College of Physiotherapists, etc.): ______
5. Please list other provinces/states and countries in which you are registered with a regulatory body as a manual osteopathic therapist (e.g. BC, QC, etc.)______
6. Please estimate the number of clinical hours you work on a weekly basis:______
7. Briefly describe your workspace (e.g. multidisciplinary clinic, home clinic, hospital, etc.)
______
8. Student members: please name the school you are currently attending:
______
If more space is needed, please use the reverse of this page
Alberta Association of Osteopathic Manual Therapists APPLICATION FOR MEMBERSHIP FOR THE AAOMT
Website information All graduates must be listed on the AAOMT website for verification of membership with insurance companies. You may also wish to have more information added to the website for clients to find and/or contact you.
Would you like your clinic number and address listed on the website (for graduates only)? Yes/ No
If yes, please indicate the following for posting on the website:
City/Town:______
Phone Number:______
Would you like your email address posted on the website for clients to find and/or contact you? Yes / No
If yes, please list applicable email address:______
DECLARATIONS
1. Have you ever been convicted or charged with, and not found not guilty or acquitted of, a criminal offence? Yes / No 2. Has there ever been a finding of professional misconduct, incompetency or incapacity in Alberta in relation to the profession or another health profession, or in another jurisdiction in relation to the profession of osteopathic manual therapy or another health profession? Yes / No 3. Is there a current proceeding against you for professional misconduct, incompetency or incapacity in Alberta in relation to another health profession, or in another jurisdiction in relation to the profession of osteopathic manual therapy or another health profession? Yes / No 4. If you answered yes to one or more of these questions, have the details of all convictions, cases and proceedings been previously provided to the AAOMT? Not applicable / Yes / No
If you answered yes to one or more of questions 1 to 3 and have not previously provided the details to the AAOMT, please attach a sheet of paper providing details.
If you answered yes to question 4 you do not have to resubmit the information.
GENERAL DECLARATIONS
I hereby certify that all statements I have made in all parts of this registration form are true and complete to the best of my knowledge and belief. I understand that a false or misleading statement may disqualify me from registration or may be cause for revocation of any registration which may be granted to me.
Dated this day of,______Day Month Year
Signature______Printed Name______
Alberta Association of Osteopathic Manual Therapists APPLICATION FOR MEMBERSHIP FOR THE AAOMT
To be enclosed with this application:
1. Valid copy of current liability insurance (if graduated and practicing as an osteopathic therapist)
2. Copy of Diploma or Certificate (if graduated)
3. Two passport size photo graphs taken in the last 6 months, please sign and date the reverse of the photograph
4. Two letters of recommendation. These letters can be from a lawyer, a physician, or any other health practitioner. The person writing the letter must have known you for at least 6 months, if not please explain why. These recommendations will be checked so make sure that the person recommending you is happy to be contacted. If applying from abroad the letters can come from overseas but must be in English.
Alberta Association of Osteopathic Manual Therapists