Therapist application form Therapist/Teachers Application form The information you provide will be kept secure and wont be shared with third parties. Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Home phoneMobile phoneSkype adressWebsiteWhat would you like to offer at PuyssentutPlease say whether you would like to work one-to-one and/or in a group/workshop setting. Are you insured to work with clients when overseas?YesNoWhat qualifications do you have?How long have you been working with clients in your field?What experience do you have of working with clients who have cancer (or other long-term/chronic illnesses)?What equipment would you need us to provide?What payment would you require?I need my travel expenses paidI do not need my travel expenses paidI am happy to volunteer my servicesI would like to receive some payment for my servicesAre you registered as self-employed/have your own company?YesNoPlease provide us with your VAT numberWould you be prepared to share your room with another staff member?YesNoWould you be willing to help with other tasks during the week, such as preparing meals and serving at the juice bar?YesNoDo you have any dietary requirements?YesNoPlease tell us your dietary requirementsDo you have any health issues we should know about?YesNoPlease tell us about these.How did you hear about Puyssentut?From a friend or colleagueFrom a nurse/doctor/oncologistFrom a websiteFrom a magazine/newspaper articleFrom a brochure or flyerFrom a cancer-related support groupOtherWhich websiteWhich magazine/newspaper?Please specifyCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
