Join | Canadian Association for Colon Therapists

Applicant Name

First Last

Address

Street Address Address Line 2 City Province Postal Code

Please answer the following questions (check applicable):

Are you currently working as a Colon Therapist Practitioner?

If YES, how long have you been practitioner?

Are you a colon hydrotherapy business owner?

Did you complete a certification program?

If YES, list name of school

Year Completed

What type of colon hydrotherapy equipment have you/do you use?

Do you have First Aid or CPR training:

If yes, please indicate the name of the school

If yes, please indicate date course completed

Do you have any experience in any not-for-profit organizations?

If yes, please list

What was your role there?

Do you have any training on any other alternative health modalities?

If yes, please list the modality

If yes, please list name of school

Did you receive a diploma or certification?

If yes, please list date course completed

Please list any experience that might be a contribution to C-ACT

Please list the areas that you would be willing to donate your time in lieu of membership fee (first year only).

A paragraph stating why you are interested in membership with C-ACT?

Applicant’s Name (please print)

Date

Applicant’s Signature: