KPAB New Registration Application Form "*" indicates required fields Registration Details * I’m applying for the following registration level Student Fee - Initial $125.00 - Annual renewal $115.00 Certificated Kinesiologist Fee- Initial $180.00 - Annual renewal $135.00 Certificate in Kinesiology or equivalent 1 years training - 300 Hours Registered Kinesiologist Fee - Initial $250.00 Annual renewal $180.00 (Includes NHC Affiliation Fee) Diploma of Kinesiology or equivalent 3 years training - 500 Hours Registered Kinesiologist Senior Consultant Fee- Initial $250.00 Annual renewal $180.00 (Includes NHC Affiliation Fee) Advanced Diploma of Kinesiology or equivalent 4 years training – 650 Hours Contact Details (all required) * Title MrMrsMsMissOther Name* Clinic Name* Physical clinical address* Postal clinical address (if same as physical, please leave blank) Clinic Address Contact * * * Your Kinesiology qualifications Certificate in Kinesiology YesCopy attached - Yes Diploma in Kinesiology YesCopy attached - Yes Other accredited Kinesiology course qualifications: YesCopy attached - Yes Continuing Professional Development The following are the workshops and training hours I have completed in Kinesiology and Associated Health courses: Relevant Certificates of Competency for Kinesiology and Associated Health courses are attached and academic transcripts and evidence of hours studied are also attached for Anatomy and Physiology; Nutrition; Practice/Business Management (if applicable). Name of Core Kinesiology Courses Instructor/College Date obtained Hours Name of Core Kinesiology Courses Instructor/College Date obtained Hours Name of Core Kinesiology Courses Instructor/College Date obtained Hours First Aid Please attach a copy of your current First Aid Certificate. Payment Payment method: Electronic transfer - ASB 12-3027-0442945-00 I have arranged payment of my membership and admin fees for the following amount: Please attach your remittance receipt Professionalism Have you ever been convicted of a criminal offence? YesNo Have you ever been investigated for alleged professional misconduct? YesNo Have you been refused membership of any professional membership body? YesNo If you must answer “Yes” to any of the above, please provide details to accompany your application. I consent to my name being forwarded to the Natural Health Council and Natural Health Practitioners NZ YesNo I would like my name to appear on my annual practicing certificate as: DECLARATION I hereby confirm that the details included in this application form and my supporting documents to be true and correct. As a practitioner registered with the Kinesiology Practitioner Accreditation Board (“KPAB”) I agree to abide by the Constitution and By-Laws. As a practitioner registered with KPAB (at any level), I shall at all times abide by The Institute Code of Ethics and Conduct and maintain a current First Aid. Certificate Continuing Professional Education (CPE) has become a necessary part of a professional’s life. The purpose of CPE is to ensure Professional Practitioners regularly update their clinical skills and professional knowledge. It is a commitment to updating and furthering one’s education. attended 15 hour kinesiology-related workshop (or 2 x 8 hour workshops) OR present a 30 min kinesiology paper at a conference or recognised research workshop OR have a kinesiology article published in a journal CODE OF ETHICS AND CONDUCT Principles of ethical behaviour applicable to all kinesiologist, including those who may not be engaged directly in clinical practice. Consider the health and well-being of your client to be your first priority. Strive to improve your knowledge and skill so that the best possible service can be afforded to your client. Honour your profession and its traditions. Recognise both your own limitations and the special skills of others in the prevention and management of “dis-ease”. Protect the client’s confidences even after his or her death Let integrity and professional ability be your chief advertisement. I have read and understood and agree to comply with the above at all times during my membership with KPAB. I also understand that a membership year starts in January and finishes in December, KPAB reviews memberships annually.