p. 1/2College of Physical Therapists of Alberta operates as Physiotherapy Alberta - College + Association

Provisional Register Extension

1. Personal Information

Regulated member's name:

Registration number:

2. Liability Insurance

Details of professional liability insurance in effect after October 1, 2015.

Insurance Provider or Broker's Name Policy, Certificate or Document Number Policy Effective Date

3. Practice Hours

Hours you will provided physiotherapy services (assessment, diagnosis, treatment) or engaged in research, education or administration with respect to health or the practice of physiotherapy between October 1, 2014 and September 30, 2015. You may estimate hours to September 30.

Application

4. Supervised Practice

Primary Location

Employer name

Name of supervising physiotherapist(s)

Second Location (if applicable)

Employer name

Name of supervising physiotherapist(s)

Third Location (if applicable)

Employer name

Name of supervising physiotherapist(s)

OFFICE USE

Date received: Date approved: File number:

p. 2/2 Physiotherapy Alberta | Provisional Register Extension | August 2015

5. Declarations

Select yes or no to indicate whether a statement is true or not.

I have reviewed My Profile and declare the information is accurate. I understand that it is my responsibility under the Health Professions Act to report changes to this information within 30 days of a change occurring.

Yes No

I personally hold, and will continue to hold while a regulated member, professional liability insurance in the amount of $5 million per occurrence/patients and $5 million for the policy year which extends to all activities related to my practice of physiotherapy.

Yes No

The practice hours I reported are accurate to September 30, 2015. Yes No

Are you currently undergoing an investigation, alternative complete resolution process, hearing or appeal related to unprofessional conduct by a regulatory body outside Alberta responsible for the regulation of physiotherapists?

Yes No

Are you currently undergoing an investigation, alternative complete resolution process, hearing or appeal related to unprofessional conduct by a regulatory body responsible for the regulation of a professional other than physiotherapists?

Yes No

Have you ever been disciplined by another regulatory body responsible for the regulation of physiotherapists or any other profession that you have not reported to the College of Physical Therapists of Alberta previously?

Yes No

Have you ever pleaded guilty or have been found guilty of a criminal offence in Canada of a similar nature in a jurisdiction outside Canada for which you have not been pardoned and have not reported to the College of Physical Therapists of Alberta previously?

Yes No

I have read and understand these declarations. I understand a false or misleading statement may disqualify me from registration or may be cause for revocation of any registration for which may be granted to me.

Yes No

6. Payment

Practice permit fee 2015/2016 - $750.00

MasterCard Visa Cheque made payable to College of Physical Therapists of Alberta

Credit card number Expiry date (mm/yy)

Signature Date

p. 1/2

College of Physical Therapists of Alberta operates as Physiotherapy Alberta - College + Association

 

Provisional Register Extension

1. Personal Information

2. Liability Insurance

Details of professional liability insurance in effect after October 1, 2015.

3. Practice Hours

Hours you will provided physiotherapy services (assessment, diagnosis, treatment) or engaged in research, education or administration with respect to health or the practice of physiotherapy between October 1, 2014 and September 30, 2015. You may estimate hours to September 30.

Application

4. Supervised Practice

Primary Location

Second Location (if applicable)

Third Location (if applicable)

OFFICE USE

p. 2/2

Physiotherapy Alberta | Provisional Register Extension | August 2015

5. Declarations

Select yes or no to indicate whether a statement is true or not.

I have reviewed My Profile and declare the information is accurate. I understand that it is my responsibility under the Health Professions Act to report changes to this information within 30 days of a change occurring.

I personally hold, and will continue to hold while a regulated member, professional liability insurance in the amount of $5 million per occurrence/patients and $5 million for the policy year which extends to all activities related to my practice of physiotherapy.

The practice hours I reported are accurate to September 30, 2015.

Are you currently undergoing an investigation, alternative complete resolution process, hearing or appeal related to unprofessional conduct by a regulatory body outside Alberta responsible for the regulation of physiotherapists?

Are you currently undergoing an investigation, alternative complete resolution process, hearing or appeal related to unprofessional conduct by a regulatory body responsible for the regulation of a professional other than physiotherapists?

Have you ever been disciplined by another regulatory body responsible for the regulation of physiotherapists or any other profession that you have not reported to the College of Physical Therapists of Alberta previously?

Have you ever pleaded guilty or have been found guilty of a criminal offence in Canada of a similar nature in a jurisdiction outside Canada for which you have not been pardoned and have not reported to the College of Physical Therapists of Alberta previously?

I have read and understand these declarations. I understand a false or misleading statement may disqualify me from registration or may be cause for revocation of any registration for which may be granted to me.

6. Payment

Practice permit fee 2015/2016 - $750.00

8.0.1291.1.339988.308172

Application, Registration as a Physiotherapist

PrintButton1: RegulatedMembersName: RegistrationNumber: InsuranceProviderName: InsuranceNumber: InsuranceEffectiveDate: PracticeHours: PrimaryEmployer: PrimaryEmployerSupervisors: SeconaryEmployer: SecondaryEmployerSupervisors: ThirdEmployer: ThirdEmployerSupervisors: DateReceived: DateApproved: FileNumber: ProfileYes: ProfileNo: InsuranceYes: InsuranceNo: HoursYes: HoursNo: InvestigationPTYes: InvestigationPTNo: InvestigationOtherYes: InvestigationOtherNo: DisciplineYes: DisciplineNo: CriminalOffenseYes: CriminalOffenseNo: DeclarationYes: DeclarationNo: MasterCard: Visa: Cheque: CreditCardNumber: ExpiryDate: Signature: Date: