1.What is your first and last name?

2.I understand that my monthly supervision may not be enough to cover my supervision needs and that I am responsible for making sure that my supervision needs are met.

Yes

No

3.I agree to stay in compliance with all governing boards that oversee my work with children.

Yes

No

4.I agree to maintain current malpractice insurance.  If for some reason, I do not need to carry my own insurance I agree to discuss this with my supervisor.

Yes

No

5.I understand that my deposit secures my spot in the Certification Program and understand that if I withdraw my participation before the program begins that I will forfeit the deposit amount.

Yes

No