Registration Form

Supervision Workshop registration Form for Psychologists

Your application to attend a workshop will be taken as your agreement to the following declaration

Declaration on Enrolment

I understand that the NSW Psychologists Registration Board will only count my attendance at this workshop towards authorisation as a Psychology supervisor if:

I am currently a fully registered Psychologist in NSW in good standing with the Board (i.e. the Board has not informed me that there are any problems with my registration) and

I have been a fully registered Psychologist for a minimum of three years (i.e. registered for three years AFTER the period of provisional registration).

I declare that on the date of this workshop I will meet these requirements.

I understand that it is my responsibility to be sure that I meet these requirements. If I have any doubts as to my eligibility then it is my responsibility to check it with the Board before enrolling in this supervision workshop (workshops@hprb.health.nsw.gov.au).

I understand that workshop attendance before I have been fully registered for 3 years will not be counted by the Board after I have been fully registered for 3 years (i.e. I would be required to attend the workshop again to be eligible for authorisation as a Psychology Supervisor).

If posting your registration please print this form after filling in your details.

* Required Field
Workshop Dates & Locations	*Day 1: 9am to 5pm. Day 2: 9am to 5.30pm.
Psych Rego No.	* Number only - do not enter PS
Title
First Name	*
Last Name	*
Postal Address
Suburb
Postcode
Preferred Email	*
Preferred Phone	*
Payment method	* see Payment information below for further details
Special dietary needs, comments or questions
Cancellation Policy	Refund of 80% if your vacated place is taken by another psychologist or Refund of 50% if your vacated place cannot be filled by another psychologist
Change of Booking	Full transfer of fee to new workshop if your vacated place can be filled by another psychologist or 50% transfer of fee if your vacated place cannot be filled by another psychologist
I have read and agree to the Cancellation and Change of Booking policies and also confirm that I will meet all requirements of the NSW Psychologists Registration Board for attendance by the date of workshop.	* Please type YES in box to indicate you agree and confirm requirements
After submitted form has been confirmed return here to finalise payment

Payment Information: $360.00 for two day workshop $200 for one day workshop

Payment by Direct Deposit	Please ensure that you provide identifying information (e.g. Surname and Psych Rego No.) so that we can attribute the payment to you. We take no responsibility for direct deposits that do not have sufficient identifying information. Bank Account Details Account Name: Viva Wellbeing Pty Ltd BSB:032 267 (Westpac Bank Leichardt) Account Number: 182 380 Please note We are willing to hold a place for you while awaiting receipt of the direct deposit, but payment must be received within 7 days of your on-line registration or your place will be forfeited.
Payment by PayPal	Click here
Payment by Post	Please make your cheque payable to Viva Wellbeing Pty Ltd and post with application form to: Workshop Manager PO Box 2460 Greenhills NSW 2323 Please note We are willing to hold a place for you while awaiting receipt of the cheque, but payment must be received within 7 days of your on-line registration or your place will be forfeited.