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Membership Application

MrMrsMsMiss

First Name

Surname

Your Address

Post Code/Zip Code

Country

Date of birth (DD/MM/YY)

Profession

Professional Body & Registration/License Number

Do you have insurance to practice? YesNo

If yes, please upload a copy of the insurance document

If you are not insured to practice we can help you to get insured. Please ask at time of application.

Your Email (required)

Telephone

Please include other areas you service (include Post Code/ZIP Code)

Membership (Please tick the type of membership you applied for)
Practicing Myofunctional Therapist £150Allied Health Professional £150Other International Members £150Student Membership £50

Are you a member of any association, or other professional groups in relation to Myofunctional Therapy?

NoYes
Yes, please give details:

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