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Student Placement Form

Step 1 of 2

  • MM slash DD slash YYYY
  • Contact Details

  • Emergency contact details

  • Medical information

  • About You

  • i.e. do you have after hours comments such as sport/work that prevents you from attending late appointments. Or any medical considerations that restricts from participating in placement activities
  • Photo/Video Consent

  • I hereby give my permission to the staff of Calm and Connected to make photographic, audio, or visual recordings of me while attending Calm and Connected’s Therapy Intensive Programs. Photos/Video of me may be used as indicated below. This consent if valid for 5 years and I understand that I can notify Calm and Connected of change in consent at any time.
  • Max. file size: 256 MB.
  • Max. file size: 256 MB.
  • Max. file size: 256 MB.
  • Max. file size: 256 MB.
  • Max. file size: 256 MB.
  • Max. file size: 256 MB.
  • Max. file size: 256 MB.
  • Max. file size: 256 MB.