Test registration General Student Registration General student registration Name* First Last Enter the name you want used on your certificate of completion.Profession*Degree*Academic Institution in which degree was obtained*Licensing Body and License Number*Address* Street Address Address Line 2 City Province / State / Region Postal Code / Zip Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Enter email address you will use for all communication. i.e., if your work email bounces attachments, use a different one. This email address will receive numerous communications for the training and for consultation.Phone (home)*Phone (work)Phone (mobile)How did you hear about the training?*Do you have any allergies?*YesNoPlease avoid wearing perfumes or cologne during this training to respect those with sensitivities.Tell us about your alergies*Do you require any special accommodations?If you require special accommodations for this training sessions, tell us about them here.Prerequisites Qualified applicants will have a minimum of a Master's level training in a mental health discipline and must belong to a professional organization with a code of ethics, or be a graduate student having completed their core graduate academic coursework and have completed their practicum/internship portion of their graduate program. Graduate students must be on a licensing track and working under the supervision of a fully licensed mental health clinician. Please read the full EMDRIA prerequisites if you are a student or in a mental health field other than counselling: View full EMDRIA Prerequisites here. If you will be unable to practice EMDR with clients between the two sessions you will be unable to complete the training. All participants are welcome in my training regardless of background, sexual orientation, gender, race, culture, or religious background if you meet the above criteria. Prerequisites* I confirm that I meet all the prerequisites for this training Mandatory Participant Agreement EMDR Basic Training: Mandatory Participant Agreement Calgary You must also download and print a PDF of the agreement, and bring it with you on the first day of training: Mandatory Participant Agreement The undersigned participant acknowledges that she or he has thoroughly and carefully read, understands, and agrees to the following : 1. A significant component of the training involves clinicians practicing EMDR and related procedures in small groups under the supervision of the instructor or a qualified staff member. These practice experiences are for training purposes only and not for personal therapy. All participants should be prepared to address disturbing real life experiences as part of this training program in order to appreciate the subjective experience of EMDR as a client would and to provide valid training experiences for other participants. It is not unusual for a target memory to be linked to other, unexpected, disturbing memories or material, which might surface during or after the practice sessions. Trauma-related case material presented didactically, in consultation sessions, or on video may be disturbing to those with unresolved personal issues. In submitting their application for training, the participant affirms that they have developed appropriate self-soothing and affect/arousal management skills to cope with exposure to this type of material and will be able to employ these skills as necessary during and following EMDR training, practice and consultation sessions. It is the responsibility of the participant to seek, obtain and pay for appropriate professional assistance if needed. Providing such assistance is not part of the training. 2. You are expected to maintain a spirit of cooperation and mutual support for all in the training. The trainer reserves the right to withhold or dismiss from training any participant that she deems unable to successfully complete the training for any reason. 3. This experiential training is intended to prepare clinicians to apply EMDR for clinical purposes only and will not qualify the participant to train others in EMDR. Attempts to train others in EMDR without meeting the standards as defined by the EMDR International Association would represent a violation of professional ethics and standards. Additionally, in signing this document, I relinquish my right to teach EMDR in Western Canada. 4. In order to assure confidentiality of personal and clinical information, audio/video recording by participants is not allowed. It is expected that all participants shall maintain the highest ethical standards of confidentiality regarding all personal and clinical information shared by others in this training. Confidentiality shall apply to all consultation sessions and practicum experiences: specifics may be discussed only with members of the immediate consultation or practice group, the participant’s group consultant, practicum supervisor and trainer(s). 5. A Certificate of Completion will be issued to all participants who satisfactorily complete the entire training and 10 consultation hours. Your signature* I confirm I have read and agree to the terms of the Participant Agreement and will print and bring it signed to the training. By checking this box you confirm that you have read, understood, and will be bound by the terms of the Mandatory Participant Agreement above. Note: Please use the link above to download a PDF of the agreement. It should be printed, signed, and brought with you to the first day of training.Complete your registrationSignature This iframe contains the logic required to handle Ajax powered Gravity Forms.