New Membership Application Form "*" indicates required fields 1Consent2Contact Info3Other Info4Statement of Ethics Type of Membership* Associate Member General Member External Member ConsentIn order to conform to the Personal Information Protection and Electronic Documents Act (PIPEDA), please check all boxes that apply for you.I give my permission: To the TTNO to collect and use my personal information. This information shall be used solely for the TTNO membership records, and to provide you with information about TTNO activities. It will not be released to outside parties except as required by law. For my personal information to be included in this year’s TTNO Directory of Members. To the TTNO to send me emails regarding TTNO business and upcoming events To the TTNO to use images of my person on the website, in the newsletter. Contact InfoName* First Last Phone #*ADDRESS:* Street Address City Province / State / Region Postal Code / ZIP AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do you have an email address?If so, your completed form will be sent there. Yes No Email Other InfoTherapeutic Touch Levels and/or TTNO Workshops, Retreats, Professional Development DaysAdd additional entries using the (+)Name of workshop or EventName of TeacherDate (month/year) Add RemoveBranch MeetingsI currently attend branch meetings* Yes No No, but I would like to Location of meetings attendedVolunteer SectionI would be willing to participate in/at: TTNO Conference Therapeutic Touch Awareness Week (TTAW) Task Group TTNO Committee under the Board of Directors TTNO Office Other Other volunteering STATEMENT OF ETHICS AND CONDUCT FOR THE PRACTICE OF THERAPEUTIC TOUCH® I will conduct my practice of Therapeutic Touch in accordance with the generally accepted principles of Therapeutic Touch as developed by Dolores Krieger, PhD, RN and Dora Kunz, and the Guidelines of The Therapeutic Touch Network of Ontario. In advance of Therapeutic Touch sessions, I will make clear to the client any fees which I will charge for my service. I will ensure that all interpersonal transactions between the client and me are non-exploitive and essential to her/his care. I will refrain from selling any product or other service to the client, when referred by The Therapeutic Touch Network of Ontario Referral Service. I acknowledge that Therapeutic Touch may increase the rapport between the client and me, therefore I will keep all information in strict confidence. In accordance with Personal Information Protection and Electronic Documents Act (PIPEDA), I will keep all client information in a safe, secure, private location. I will not share any information without written consent from the client. When client information is no longer needed, it will be shredded and destroyed. Unless they are directly involved in the Therapeutic Touch session, I will not take another person with me to a session. I will not use Therapeutic Touch as a basis for psychotherapy, spiritual or other counseling, unless I have the training and qualifications to do so, as well as permission of the client. I will focus on the needs of the client and will refrain from discussing my personal issues with the client. I will regularly evaluate my strengths, limitations and levels of effectiveness. I will strive for self improvement and seek to enhance my abilities by means of further education and training. In any Therapeutic Touch session, I will maintain the highest integrity, keeping the interest of the client foremost, and I will conduct all sessions in a manner that upholds the reputation of Therapeutic Touch throughout the world. I will not hold The Therapeutic Touch Network of Ontario responsible for any consequences resulting from my practice of Therapeutic Touch. I understand that, should The Therapeutic Touch Network of Ontario receive any complaints about my sessions, or my conduct, I will be notified of that complaint. If, after due process of investigation, a mutually acceptable resolution of any associated problems cannot be achieved, the TTNO has the right to withdraw my name from the list of members of The Therapeutic Touch Network of Ontario. This field is hidden when viewing the formSTATEMENT OF ETHICS AND CONDUCT FOR THE PRACTICE OF THERAPEUTIC TOUCH® I will conduct my practice of Therapeutic Touch in accordance with the generally accepted principles of Therapeutic Touch as developed by Dolores Krieger, PhD, RN and Dora Kunz, and the Guidelines of The Therapeutic Touch Network of Ontario. In advance of Therapeutic Touch sessions, I will make clear to the client any fees which I will charge for my service. I will ensure that all interpersonal transactions between the client and me are non-exploitive and essential to her/his care. I will refrain from selling any product or other service to the client, when referred by The Therapeutic Touch Network of Ontario Referral Service. I acknowledge that Therapeutic Touch may increase the rapport between the client and me, therefore I will keep all information in strict confidence. In accordance with Personal Information Protection and Electronic Documents Act (PIPEDA), I will keep all client information in a safe, secure, private location. I will not share any information without written consent from the client. When client information is no longer needed, it will be shredded and destroyed. Unless they are directly involved in the Therapeutic Touch session, I will not take another person with me to a session. I will not use Therapeutic Touch as a basis for psychotherapy, spiritual or other counseling, unless I have the training and qualifications to do so, as well as permission of the client. I will focus on the needs of the client and will refrain from discussing my personal issues with the client. I will regularly evaluate my strengths, limitations and levels of effectiveness. I will strive for self improvement and seek to enhance my abilities by means of further education and training. In any Therapeutic Touch session, I will maintain the highest integrity, keeping the interest of the client foremost, and I will conduct all sessions in a manner that upholds the reputation of Therapeutic Touch throughout the world. I will not hold The Therapeutic Touch Network of Ontario responsible for any consequences resulting from my practice of Therapeutic Touch. I understand that, should The Therapeutic Touch Network of Ontario receive any complaints about my sessions, or my conduct, I will be notified of that complaint. If, after due process of investigation, a mutually acceptable resolution of any associated problems cannot be achieved, the TTNO has the right to withdraw my name from the list of members of The Therapeutic Touch Network of Ontario. Consent* I agree to the statement of ethics and conductStatement of Ethics Signature* First Last Date* DD slash MM slash YYYY
