Please
provide us with your general information
(Please print
clearly):
Date
of application:
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Name:
First (Given) Last
(Family):
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Phone:
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Home:
Business:
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( )
-
(
)
-
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Street
Address:
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Date of Birth: Mo ___ Day ___ Yr __
Gender: M:
F:
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City:
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Prov/State:
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Postal/Zip:
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Country:
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E-mail
Address:
NB: In order to receive important
communications and updates from the SSO, we ask you to provide
a functioning personal or business email that you check
regularly. |
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Would you like to be listed in the Membership Directory
on the Shiatsu Society of Ontario web site?
Yes: No:
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If yes:
Please provide the following information exactly as you
would like it presented on the web site.
Name or Business Name:
Location (town / city where you practise):
Please provide at least one of the following:
Business e-mail address:
Business
telephone:
Optional:
Website: http://
Cell :
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Please
outline your training history:
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School: Name
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Street
Address:
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City:
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Province/State:
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Postal/Zip Code:
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Country:
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Name
of instructor:
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Style
of Shiatsu:
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Length
(hours) and Duration (dates) of training:
Please provide supporting documentation from your school
/ instructors.
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Nature of Training/Qualification (Diploma, Certificate,
Apprenticeship, etc):
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Please
list any post-graduate Shiatsu studies you have completed.
Please
provide supporting documentation from your school / instructors.
Are
you currently enrolled in continuing Shiatsu education? Yes
No
If yes,
please describe:
Please indicate your membership level:
Please check one:
| 1.
Practitioner |
Fee
| $50.00 |
|
2. Therapist |
Fee | $50.00 |
| 3.
Student |
Fee | $15.00 |
| 4. Support |
Fee
| $15.00 |
Please do not mail cash. Cheque or money order are the only
acceptable payment methods.
If you would like to extend your participation in the SSO beyond
membership, we would be delighted to put any expertise you may
have to work for us. Please circle below the areas in which you
have interest or talent.
|
Budget and finance
Education
Ethics
Fund-raising
Graphics or Web design
Insurance
Law and legislation
Leadership (Local or Municipal)
|
Networking with other professionals
Newsletter � including artwork and articles
Membership
Public relations
Publicity
Research
Other
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IMPORTANT:
Submission checklists
Please review
the appropriate checklist before submitting your application:
Therapist
Applicants must submit:
1. Completed application form
2. Copy of Diploma (must prove completion of minimum 1100
hours training)
3. Copy of current Liability Insurance or proof of application
4. Copy of current CPR certificate (be sure that valid
dates are visible)
5. Your Anatomy and Physiology course certificate or verification
of completion.
6. A signed and witnessed copy of the Shiatsu Society of Ontario
Code of Ethics
(see below).
7. A cheque or money order for $50, payable to "Shiatsu
Society of Ontario".
Practitioner
applicants must submit :
1. Completed application form
2. Copy of Diploma (must prove completion of minimum 500
hours training)
3. Copy of current Liability Insurance or proof of application
4. Copy of current CPR certificate (be sure that valid
dates are visible)
5. A signed and witnessed copy of the Shiatsu Society of Ontario
Code of Ethics
(see below).
6. A cheque or money order for $50, payable to "Shiatsu
Society of Ontario".
Student
and Supporting applicants must submit:
1. Completed application form
2. A signed and witnessed copy of the Shiatsu Society of Ontario
Code of Ethics
(see below).
3. A cheque or money order for $15, payable to "Shiatsu
Society of Ontario".
Shiatsu Society
of Ontario
CODE OF ETHICS
»
Please sign
and
witness
this code of ethics where indicated below, and
enclose it with your application.
(1)
Environmental / Social
Members
of the SSO are obliged to be aware of their role and responsibility
to their community, locally and globally.
(2)
Conduct
SSO members
are professionals who conduct themselves ethically and in accordance
with the standards and quality of their training. They represent
themselves and their certification honestly and practice only
those modalities in which they are qualified.
(3)
Health
Members
of the SSO are required to use Health History Questionnaires
when seeing new clients and they must keep accurate follow-up
records of each treatment that they give. They realize that
part of their responsibility to their clients is to recognize
when the practice of Shiatsu will not be beneficial to the client�s
condition and they will take appropriate steps to refer the
client to the appropriate western medical practitioners.
(4)
Image
SSO members
are required to pay scrupulous attention to cleanliness and
hygiene in their practice and strive to create a relaxing atmosphere
in which their clients may receive treatment.
(5)
Confidentiality
SSO members
hold the information that their clients give them, in whatever
form, in the strictest confidence. They strive to maintain clear
communication with their clients and willingly describe the
techniques used in treatment for their client�s benefit.
(6)
Trust
SSO members
foster relationships of trust with their clients and establish
clear boundaries with their clients in order to create an atmosphere
of safety.
(7)
Respect
SSO members
honour the client�s physical and emotional state and in no way
take advantage of the therapeutic relationship. They are considerate
of the client�s personal comfort zone. They respect a client�s
requests as much as possible, within the scope of professional
and ethical limits. They do not engage in sexual activity with
a client. They acknowledge the inherent worth and individuality
of each person and do not unjustly discriminate against clients
or peers.
(8)
Integrity
SSO members
practice Shiatsu in a professional and compassionate manner,
representing themselves, their practice and their art in an
honest, accurate and ethical way. They conduct business honestly.
(9)
Courtesy
SSO members
communicate clearly and directly with others, both professional
and public, in an open and courteous manner. They respect the
standards set by the authorities that govern the practice of
Shiatsu and Asian Medicine within Canada and wherever they are
in practice.
(10)
Excellence
SSO members
recognize that at the core of Shiatsu rests the notion of �practice.�
To that end they regularly undertake professional assessment
and personal development to increase their skill and ability
so as to better themselves and to better serve their clients.
(11)
Misconduct
SSO members
are expected to conduct themselves according to the above guidelines.
If circumstances should arise where the conduct of a member
is questioned, this member will be subject to a review by the
Society�s Ethics and Complaints Committee. The inquiry will
ascertain the nature of the complaint and give an opportunity
for all concerned parties to express their views. Should it
be found that the issue can be rectified, all help possible
will be given to assist the member in rectifying the situation
and conducting their practice more efficiently. However, should
it be found that the member in question was in violation of
the Code of Ethics laid out by the Society, appropriate action
will be taken which may result in the termination of their membership.
I,
_______________________________, have read and agree to abide
by the Code of Ethics and Principles of Practice, as outlined
above by the Shiatsu Society of Ontario.
Signed by:
___________________________, this ______ day of ____________________,
200_.
[Applicant
name]
Witnessed by:
___________________________, this ______day of ____________________.
[Witness name]
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FOR
SSO ADMINISTRATIVE USE
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| TYPE: _____ |
NEW_____ |
RENEWAL_____ |
|
| Fee _______ |
Certificate_______ |
Insurance_______ |
Ethics_______ |
| Web Listing_______ |
STATUS: |
Accepted_____ |
Action: |
|
