Trainee Application Form and Agreement
Mickel Therapy Practitioner Training in Australia
Thank you for choosing to apply for Mickel Therapy Practitioner Training. This form will help us to find
out more about you and what you are hoping to achieve by taking this training.
You can return this form by:
1. Either cutting and pasting the entire contents of this document into an email, filling in and
returning by email to Kim Knight at: info@mickeltherapy.co.nz
2. Or fill out this word document and send it as an attachment by email to Kim Knight
info@mickeltherapy.co.nz
Full Name:
Landline Phone (for your interview):
Cell Phone:
Email:
Skype (for your interview):
Address:
Gender:
Male
Female
Date of Birth:
Occupation:
Are you working:
Part-time
Full-time
Not currently working
How did you hear of Mickel Therapy?
Kim Knight, Senior Mickel Therapist and Mickel Therapy Trainer
Ph +64 9 833 6553 Mob +64 21 410 633
info@mickeltherapy.co.nz
www.mickeltherapy.co.nz
Have you experienced Mickel
Therapy as a client?
Yes
No
If yes:
When: Year / Date:
Name of your practitioner:
What was your experience of
Mickel Therapy? What results
did you have?
Have you experienced other
therapies as a client?
Please list…
Have you trained in other health Please list…
modalities as a practitioner?
Are you qualified in any other
therapies?
Any other Qualifications
Please list…
Kim Knight, Senior Mickel Therapist and Mickel Therapy Trainer
Ph +64 9 833 6553 Mob +64 21 410 633
info@mickeltherapy.co.nz
www.mickeltherapy.co.nz
Why do you want to do the
Mickel Therapy Training?
What do you hope to achieve?
Are you doing the training to…
1. To become a practitioner
2. For personal interest only
3. Initially for personal interest and may become a practitioner
later
(delete which doesn’t apply)
Brief work history
Relevant life experiences /
insights you have you feel will
help you deliver Mickel Therapy
effectively?
Kim Knight, Senior Mickel Therapist and Mickel Therapy Trainer
Ph +64 9 833 6553 Mob +64 21 410 633
info@mickeltherapy.co.nz
www.mickeltherapy.co.nz
What skills and personal
qualities do you have that will
assist you in delivering Mickel
Therapy effectively?
Do you have any relevant
voluntary work experience?
Any other relevant information
you feel will support your
application?
1.
References
Please supply the names and
contact details of two referees.
In what capacity do you know
2.
them?
(We will not contact anyone
without your prior permission).
How did you hear about Mickel
Therapy and this training
course?
What is your preferred day and Day of week:
time for a phone interview?
Time of day:
Please supply a landline or
skype name for Kim to contact Landline phone or skype handle:
you on.
Kim Knight, Senior Mickel Therapist and Mickel Therapy Trainer
Ph +64 9 833 6553 Mob +64 21 410 633
info@mickeltherapy.co.nz
www.mickeltherapy.co.nz
Trainee Practitioner Agreement Form
Personal Details
Full Name: ________________________
Address: ______________________ ______________________ ______________________
Phone (landline): ________________________
Phone (cell): ________________________
Email: ________________________
Agreement
Please sign this form if you agree to the following statements and conditions.
“I (name) ------------------------------ agree that the information given in this form is accurate and correct.
I have read and agree with the Terms and Conditions, including Confidentiality, Ownership, Copyright,
Data Protection as laid out in the Mickel Therapy Practitioner Training Information Pack and
Application Form.
I agree to adhere to the Course Booking Fees, Payment and Cancellations Policies as outlined in the
Training Fees Information Sheet”.
Signature: ________________________ Date: ________________________
This form must be returned by email – details on next page…
Kim Knight, Senior Mickel Therapist and Mickel Therapy Trainer
Ph +64 9 833 6553 Mob +64 21 410 633
info@mickeltherapy.co.nz
www.mickeltherapy.co.nz
Thank you for filling in this form!
This form must be returned by email:
1. Either fill in the information in this word document, type your name in the signature spot and
email to Kim info@mickeltherapy.co.nz
2. Or cut and paste all the above information into an email, type your name and the date in and
email to Kim info@mickeltherapy.co.nz .
By emailing this form you expressly give your consent to the above terms and conditions.
The Next Step
Once Kim has received your application form she will be in touch very soon to arrange an interview.
This is a very informal process so please don’t fret!
Once your application has been approved, you will be asked to pay either your deposit or full payment
for the 5 day training (depending on the date you apply, either a deposit or full payment will be due –
please see the training information sheet for details of costs).
We look forward to seeing you at the training!
Kim Knight, Senior Mickel Therapist and Mickel Therapy Trainer
Ph +64 9 833 6553 Mob +64 21 410 633
info@mickeltherapy.co.nz
www.mickeltherapy.co.nz