#304 1212 West Broadway APPLICATION FOR CREDENTIAL AND PRIOR LEARNING ASSESSMENT (CPLA) PERSONAL INFORMATION (PLEASE PRINT): Surname First Initials Previous Surname Date of Birth DD/MM/YY MAILING ADDRESS: Street Address City Province/State Postal Code/Zip Home telephone # Cell # Business telephone # E-mail Address EDUCATION AND REGISTRATION INFORMATION: Name and address of school where massage therapy program completed Year program completed Number of hours in program Have you ever been registered as a massage therapist in another province, state, or country? Yes No If yes, in what province/state/country? Are you registered with any other health profession in British Columbia? Yes No If yes, with which college(s)? Send this form to the College of Massage Therapists of British Columbia, with the credential evaluation fee of $300.00 This application will be valid for two years only.
CITIZENSHIP/RESIDENCE STATUS: Do you have Canadian citizenship, permanent resident status, or a valid work permit? Yes No One of the above is required at the time you register. If you will not meet this requirement by the time you are ready to register, please contact the College for information. FLUENCY: Can you speak and write either French or English with reasonable fluency? Yes No Acceptable evidence of fluency in written and spoken English or French is required to become eligible for registration. If you were not educated in Canada, please contact the College for information on meeting this requirement. Please indicate your preferred language of communication with the College (circle one). English / French DECLARATION OF REGISTRATION REQUIREMENTS: Please answer the questions below. You are required to answer the following questions at the time you register. We are requesting this information now to provide early notification to the College. If there is an issue so it can be addressed during the application process and to avoid delaying your registration when you have met the other registration requirements. 1. Have you ever been convicted of a criminal offence? Yes No 2. Has there ever been a finding of professional misconduct, incompetence, or incapacity or any like finding in British Columbia or any other jurisdiction in relation to massage therapy or another health profession? Yes No 3. Is there a current proceeding against you involving an allegation of professional misconduct, incompetence, or incapacity or any like finding in British Columbia or in any other jurisdiction in relation to your practice of massage therapy or another health profession? Yes No 4. Have you made an unsuccessful application for registration as a Health Professional in British Columbia or another jurisdiction? Yes No 5. Have you made an attempt to pass a licensing examination in British Columbia or another jurisdiction that has not yet resulted in a passing grade? Yes No If you answered yes to one or more of these questions, please attach a letter giving the details. I acknowledge that the personal information provided on this form is used by the College to determine if I meet the requirements for registration in British Columbia and for research and other projects related to the eligibility for registration of massage therapists trained outside British Columbia and is collected, used, and disclosed in accordance with the College Privacy Policy. I hereby certify that all statements I have made in all parts of this application form are true and complete. Please note that signing a document that you know provides false or misleading information may lead to a refusal of your application for registration.. Dated this day of, at Day Month Year City
#304 1212 West Broadway Dear Administrator: Re: Application for credentialing An applicant for registration with the College of Massage Therapists of British Columbia is requesting that you provide the College with information about the massage therapy program he/she completed at your institution. Applicants for registration are required to have completed a massage therapy program that provides competencies equivalent to those provided by the programs currently being offered in British Columbia. Please complete the attached form and send it directly to the College with the following documents: 1. Official transcripts, supervised clinical practice hours, final grades, credits 2. Course descriptions/course syllabuses AND the grading scale relevant to the applicant s time of study. The transcript and course descriptions will enable us to determine if this applicant is eligible for registration in British Columbia as a massage therapist. Thank you for your assistance in this matter. If you have any questions, please contact the College of Massage Therapists of BC at info@cmtbc.ca Yours sincerely, Administration College of Massage Therapists of British Columbia
#304-1212 West Broadway TRANSCRIPT REQUEST FORM To be completed by the applicant. Authorization to Release Information: Please complete this section and send this form to the school(s) at which you completed your massage therapy education. I, hereby authorize Name Name of school Address of school to provide the requested information concerning my massage therapy education to the College of Massage Therapists of British Columbia. Date To be completed by the massage therapy institution: Name of applicant (last name, first name, middle initial) Name of massage therapy institution Address of massage therapy institution Telephone number: ( _ ) Fax number: ( ) E-mail address: Is your school accredited? Yes / No If yes, who approves your school? Minimum academic entrance requirement: Start and finish dates of the applicant s program (month, year) Length of the program in hours
Please complete both pages of this document and return it directly to the College of Massage Therapists of British Columbia, at #304-1212 W. Broadway Vancouver BC V6H 3V1 with the following documents: An official transcript with final grades, a record of supervised clinical practice hours completed and course descriptions/syllabuses used at the time the applicant completed the program. Program Content Information Subjects Theory hours Practical hours Health Sciences: Anatomy Physiology Musculoskeletal Anatomy Pathology Pain and Stress Pharmacology Public Health and Prevention Research Self Care Surgery Kinesiology Nutrition Neuroanatomy Neurophysiology Massage Therapy: Clinical Assessment Massage Theory and Techniques Massage Treatments Remedial Exercise Hydrotherapy Actinotherapy Professional Environment: Business, Ethics, and Professional Regulation Communications First Aid and CPR Total Hours Theory Practical This form was completed by: Name Position Date Please place your school seal and/or stamp here. Please attach the applicant s transcript(s), grades, clinical practice hours, course descriptions and grading scale to this document and return it to the College of Massage Therapists of British Columbia.