APPLICATION FORM FOR MEMBERSHIP OF MIZAN FOUNDATION Name(Required) First Last Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Email Website Instagram Facebook Date Original Course Attended MM slash DD slash YYYY Treatment swaps - please list name of practitioner and date(Required)I have taken the following Mizan courses since Practitioner TrainingRe-assessing - please name assessor and date(Required)Please list any on-going learning you have undertaken, for example, workshops attended, books you've read, etc.(Required)Agreement(Required) Code of Practice and Ethics The aim of the Mizan Therapy Code of Practice and Ethics is to set out the basic, minimum standards that are expected of MIzan Practitioners. 1. Definition and scope of Mizan Therapy 1.1 Mizan Therapy (Mizan) is the use of abdominal massage to promote and enhance the health and well being of the individual. 1.2 Compliance with the Mizan Code of Practice and Ethics is mandatory for recognised practitioners of Mizan. The practitioner must ensure that s/he knows the details of Code. 1.3 Mizan cannot and does not exclude conventional medicine and orthodox healthcare practitioners from patient care and treatment. 2. Consent 2.1 Informed consent, voluntarily given, is essential prior to commencement of any treatment. 2.2 You must explain the treatment and its likely effects. 2.3 Some clients, because of their age, illness or mental capacity cannot give consent to treatment. In such cases you should obtain clear written consent from someone authorised to give consent of behalf of the client. In this situation you must ensure that an authorised person is present during the treatment. 2.4 If you decide you must discontinue treating a client, you must do all you can to help them find an alternative source of care. 3. Relationship with the Client 3.1 You will show respect for the religious, political and social situation and views of any individual irrespective of age, race, colour, creed, gender or sexual orientation, and must never seek to impose your own beliefs on a client. 3.2 You will behave in an honourable and courteous manner with clients and the public. Proper moral conduct must always be paramount in relations with clients; you must behave with respect, courtesy, dignity, discretion and tact. Your attitude must be professional, competent, empathetic, realistic and supportive, thus encouraging uplift in the client’s outlook and belief in a progression towards good health. 3.3 You must behave professionally with a client. The client places trust in your skill, care and integrity, and it is your duty to act with due diligence at all times and not to abuse this trust in any way. 3.4 You must never claim to ‘cure’. The possible therapeutic benefits may be described but recovery must never be guaranteed. 3.5 At the first consultation you should ask the client what medical advice they have received and enter the response in the client’s records. If you later think that a client has an additional, different or previously disclosed disorder, you must advise them to consult a doctor. The advice must be recorded in the client’s records for your own protection. 3.6 Before treatment, you must explain what is involved, including such matters as the consultation process, the length of visits, fees etc. 3.7 You must act with consideration concerning fees and justification for treatment. Clients are entitled to refuse treatment, ignore advice and make their own decisions on health, lifestyle and money. 3.8 You, and all those who work with you, must not disclose or allow to be disclosed, any information about a client (including the fact of their attendance) to any third party, including members of the client’s family, without the client’s consent unless it is by due process of the law or for immediate protection of or avoidance of identifiable real risk to a third party, in which case the member is advised to obtain legal advice. 3.9 No third party, including assistants and members of the client’s family, may be present during the course of the consultation with an adult client without the client’s express consent. However, members working with children, severely disturbed clients or those of the opposite sex should give due consideration to the need to safeguard themselves by having a third party present in the treatment room or in the treatment premises. 3.10 Mizan Therapy is not approved as ‘medical aid’ under UK law. It is a criminal offence for a parent or guardian not to seek medical aid for a child under the age of 16 years. Therefore the member should secure a signed and dated statement from a parent or guardian who refuses to seek medical aid. 4. Professional Awareness 4.1 You must ensure that your health and personal hygiene do not jeopardise the welfare or health and safety of your clients. You must not eat, drink or smoke while at practice. 4.2 You must not treat a client whose requirement exceeds the your capacity, training and competence. Where appropriate you should refer your client to a more appropriately qualified person. 4.3 You must not presume specialist knowledge unless you have the training and qualifications. 4.4 You must comply with local and national legislation and be aware of current laws that affect your practice. 5. Administration and Publicity 5.1 You must not use titles or descriptions to give the impression of medical or other qualifications. You must make it clear to clients that you are not medically qualified. 5.2 Advertising must be dignified in tone and must not claim to cure any disease. 5.3 You must ensure that you keep clear, comprehensive and dated records of treatments and any advice given. If you store records on a computer, make sure they are protected by a password. Storage of hard copies must be in a locked cabinet. You must keep up to date with Data Protection requirements for storage of client records. 5.4 In order to be able to determine that any given treatment administered is appropriate and reasonable, it is the responsibility of the practitioner to ensure that their client notes/records are sufficiently thorough and accurate so that they can demonstrate that the treatment was appropriate and was carried out safely and competently. 6. Working with Other Healthcare Professionals 6.1 You should seek a good working relationship with other health professionals and work in a co-operative manner with them, and recognise and respect their particular contribution within the healthcare team, irrespective of whether they perform from an allopathic, alternative or complementary base. 6.2 You must not contradict instructions or prescriptions given by a doctor. 6.3 You must not advise a particular course of treatment or specific drugs. 6.4 You must never give a medical diagnosis to a client in any circumstances, as this is the responsibility of a qualified medical practitioner. However, it may be appropriate to encourage the client to visit their GP if you have any concerns, and in this case you should clearly record this action. 6.5 You should treat other Mizan practitioners with respect. If a client of another practitioner contacts you for any reason, you must not give advice, opinion or treatment but refer her to her practitioner. If you or the client have any concerns about the treatment she has received, she should contact Mizan Therapy using this email address: feedback@mizantherapy.com. I agree to abide by the Mizan Code of Practice and Ethics.Are you a new member?(Required) Yes No Choose 'yes' if you are a new member and your training fee includes membership for twelve months.How often do you want to pay?(Required) £5 every 30 days £60 a year New member, monthly payments New Member, monthly payments Please confirm here. Your course entitles you to a free years membership, after that you will be paying £5 every 30 daysNew member, yearly payments New Member, yearly payments Please confirm here. Your course entitles you to a free years membership, after that you will be paying £60 every yearMember, monthly payments Monthly Member Please confirm here. £5 every 30 daysMember, yearly payments Yearly Member Please confirm here. £60 every yearTotal This will show the amount of your next payment - for new members this will be in 12 months time.Credit Card(Required)Card Details Cardholder Name