Form

Membership Application for

the Association of Somatic and

Integrative Sexologists (ASIS)
Instructions
- Please read the Code of Ethics and Ethical Codes of Practice before completing the form.
- Please note that ALL Associate and Professional applicants must provide two referees who will be contacted by ASIS.
- All information given is confidential.
- This is an online form. It needs to be completed in one sitting at your computer, therefore we strongly recommend you have the following information to hand before starting the form:
  - Business Details
  - Information about ASIS Recognised Professional Training
  - Information about other Professional Training
  - Information about Continuous Professional Development Training
  - Information about Personal Development Courses
  - Names and Websites of professional bodies you are registered with
  - Details about your professional supervision
  - Details of two referees
  - List of therapies you wish covered by insurance
  - Copies of training certificates and supporting documents to hand
- * indicates a requires field
- The membership application form needs to be completed in full by the applicant and submitted online, along with scanned copies of the applicant’s signature and all relevant supporting documentation.
- When you submit the application form, you also need to make payment - full details are given in Section 9.
- PLEASE NOTE THAT NO APPLICATIONS WILL BE CONSIDERED WITHOUT FULL PAYMENT (see section 9). IF, FOR ANY REASON, YOUR APPLICATION IS TURNED DOWN, YOUR PAYMENT WILL BE RETURNED, MINUS THE £10 PROCESSING FEE
- Any applicant with a history of mental health problems must inform the registrar on application.
- This form can be completed on a PC/Mac and Tablets only. Please note - do not try and complete this form on a mobile phone as some elements will not function correctly.
CONTENTS:

Section 1 - Membership category
Section 2 - Personal details
Section 3 - ASIS recognised professional certifications
Section 4 - Other professional training
Section 5 - Professional supervision & peer support
Section 6 - Disclosure
Section 7 - Applicant's declaration and signature
Section 8 - Applicant's references
Section 9 - Membership fees & payment
Section 10 - Insurance
Section 11 - Documentation check list

Section 1: Membership Category

If you are unsure about which category to apply for, please reread Membership Categories.
I am applying for membership as a: *
Please confirm the following: *

I confirm that I have read and agree to abide by the ASIS Code of Ethics and Ethical Codes of Practice
Section 2: Personal Details
Legal First Name, Last Name and Title: *

Prefix First Name Last Name
Any other names you are currently known by e.g. professionally known as...
Gender: *
If you selected other, please specify:

Home Address *

Street Address
Street Address Line 2
Town/City	County
Postcode	Country

E-mail: *

Confirmation Email
Phone Number:
Mobile Number: *
Date of Birth: *

- Day - Month Year
Job Title:
We plan to have a directory of members in the future, listing name and website of practitioners. If you wish to have your name and website listed in our future Member’s Directory, we require your permission.

Yes No
Name to be published:
Website to be published:
Business Details
Organisation (where appropriate):

Business Address

Street Address
Street Address Line 2
Town/City	County
Postcode	Country

Phone Number:
E-mail:

Confirmation Email
Website(s):

Section 3: Other Professional Training
List relevant Professional Training
- Somatic Sexology (e.g. Certified Sexological Bodywork / Psychosexual Somatics® Therapy / Sexual Surrogacy / Tantra Massage)
- Bodywork (e.g. lomi lomi / myofascial bodywork / remedial massage / Swedish massage / Thai massage / trigger point)
- Energy work (e.g. Bach flowers / breathwork / homeopathy / polarity therapy / reflexology / Reiki / Shiatsu / vortex)
- Movement practices (e.g. chi kung/qi gong, five rhythms/dance, yoga)
- Sexology (e.g. clinical sexology / sex coaching / sex education / sex therapy)
- Talk-based disciplines (e.g. coaching / counselling / psychotherapy / psycho-sexual therapy)
- Teaching / facilitator trainings
- Transpersonal work (e.g. Buddhist / Quodoushka / shamanic / Tantra / Taoist teachings)
Please complete the following information for each of the professional training programmes you have undertaken:
Continuous Professional Development (CPD)
Continuous Professional Development (CPD). Please complete the following information for each of the events/training you have attended:
Personal development courses / path / practice(s):
Which professional bodies (in this or related fields), if any, are you registered with?: *

Section 7: Applicant's References
For Professional and Associate Applications only
- Every Professional and Associate membership application must be supported by two referees, whom ASIS will contact directly.
Requirements for Referees
1. The referees must not be the applicant's partner, relative nor a member of the ASIS committee.
1. Professional reference: One referee must have known the applicant in a professional capacity and be either a trainer or supervisor.
2. Character reference: One referee must have known the applicant for a minimum of two years and be a person who is professionally qualified.
3. Referees may be required to state their profession and qualifications
Details of Referee 1 - to be completed by applicant:
Full Name: *

First Name Last Name
Profession/Job Title: *
Website:
E-mail: *
Phone Number: *
Mobile Number:
ASIS Membership Number (if applicable)
Details of Referee 2 - to be completed by applicant:
Full Name: *

First Name Last Name
Profession/Job Title: *
Website:
E-mail: *
Phone Number: *
Mobile Number:
ASIS Membership Number (if applicable)

Section 8: Membership Fees & Payment
Membership Costs

Professional Membership: £65
Associate Membership: £35
Student Membership £15

In addition all applications incur a one off £10 form processing fee.

Payment to be made as a single payment by BACS to:

The Association of Somatic and Integrative Sexologists,
Bank: Barclays
Account number: 60092770
Sort code: 20-95-61

For international transfers:
IBAN: GB04 BARC20956160092770
SWIFT / BIC: BARCGB22
Please email payments@the-asis.org confirming the payment amount, the date of payment and the reference (please use your name) on the bank transfer
Membership Required:
Voluntary Contribution:
ASIS is a voluntary organisation and its set up costs have been met by founding members.
There are a number of projects that can happen more quickly with more funds.
Total to Pay for Professional Membership (including voluntary contribution if applicable):
Total to Pay for Associate Membership (including voluntary contribution if applicable):
Total to Pay for Student Membership (including voluntary contribution if applicable):

Section 10: Check-List

Please scan / photograph and email a copy of your training certificates and any other supporting documents to membership@the-asis.org including in the subject line the unique id reference that you will receive on submission of this application form

Documentation:

	Yes	No
Training Certificates
Other Supporting Evidence
Payment Sent

Membership queries and payments

If you have any queries regarding the application form please contact the ASIS Membership Secretary: membership@the-asis.org

Please email payments@the-asis.org confirming the payment amount, the date of payment and the reference (please use your name) on the bank transfer.

Please note that no applications wll be considered without full payment. If, for any reason, your application is turned down, your payment will be returned, minus the £10 processing fee.
Date form completed

- Day - Month Year
Please complete the security box below and then press the "Submit" button. The information you have provided will be sent to and reviewed by BGi.uk who will then confirm the cost of insurance to you.
Insurance arranged by BGi.uk Email: yogaform@BGi.uk.com Telephone: 01367 246157
Bordengate Insurance and BGi.UK are trading styles of H J Roelofs (UK) Ltd which is authorised and regulated by the Financial Conduct Authority (FCA). Oour Financial Services register number is 307129. Company Registration no. 3464365

Terms & conditions on www.bgi.uk.com and available on request.
ASIS v101015
Should be Empty:

	Yes	No
Do you have a conviction that is not spent under the Rehabilitation of Offenders Act 1974?
Have you ever been refused / expelled from membership of any professional body / register on the grounds of professional misconduct?
Have you ever been the subject of any other disciplinary action, investigation, proceeding or enquiry?
Are you currently or likely to be the subject of any disciplinary action, investigation, proceeding or enquiry?
Has your fitness to practice been impaired for any reason including health or personal circumstances?
Have you ever had any psychiatric diagnosis or serious mental health problems?
Are there any other factors that could call into question your suitability for membership?
Have you ever had a serious complaint or claim made against you for any of the therapies you will be practising under your ASIS membership and for which you wish to be insured?

Membership Application for

the Association of Somatic and

Integrative Sexologists (ASIS)

Section 1: Membership Category

Section 2: Personal Details

Business Details

Section 3: Other Professional Training

Section 4: Professional Supervision & Peer Support

Peer Support

Section 5: Disclosure

Section 6: Applicant's Declaration

Section 7: Applicant's References

Section 8: Membership Fees & Payment

Section 9: Insurance

For Completion by Professional Membership Applicants Only

Section 10: Check-List

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country