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CERTIFIED PROFESSIONAL MEMBERSHIP APPLICATION FORM

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SPECIALTY CERTIFICATION APPLICATION

 

Club/Organization | Fellow | Instructor/Trainer/Coach | School/Institute/Center| Researcher | Writer/Journalist | Stage/Media Personality | Professional Speaker


This form is not active yet.  You may print it and send it to the address below.  Email: WorldPolyamory@aol.com.

Become a Professional Member of the World Polyamory Association (WPA) and receive recognition in your field while increasing referrals to you and your organization. Our recognition and feedback program assures that our clients receive the highest possible quality for their time and money. Members feel more confident about recommending clients to other members they may not have met in person when they can review your credentials and ratings to make better decisions about you and your service. Our goal at the World Polyamory Association is to make better matches for everyone, not only personally but professionally. We desire to match you, our clients and customers, with the best services and products that match you and your needs. When you as a provider receive constructive feedback from clients and other members, you’re able to improve and offer a better product or service to your clients.

Please provide the following contact information:

First Name
Last Name
Middle Initial
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Please provide your account information:

User Name
Password
Confirm Password

Post Nominals (credits after name)


Associations and recognitions (use separate email if necessary)


Statement promoting your business to appear in the Directory of Professionals?


How does your business serve the poly community?

SPECIALTY CERTIFICATION APPLICATION

To become Board Certificated in each of the Specialty Certification categories listed below, a one time only application and processing fee of $50 is required for each Specialty Certification. Beautiful wall certificates suitable for framing are available for an additional $25. Your application and credentials will be reviewed by our committee and upon approval, you or your organization will be posted on our web site as a certified Professional Member of the World Polyamory Association.  Professional Membership ($75)  must be current to be included in our professional directory.

Fill out a separate application for each specialty category you are applying for. We are now offering the following:  Let Your Expertise and Accomplishments Speak for Themselves

Specialty Certification Application:

Club/Organization
Fellow
Instructor/Trainer/Coach
School/Institute/Center
Researcher
Writer/Journalist
Stage/Media Personality
Professional Speaker

I am a Presenter and/or Workshop Leader and wish to be considered for the World Polyamory Association Faculty Membership.  

Descriptions:

CLUB/ORGANIZATION

Do you have a club, organization or group in your field? Do you offer regular meetings that serve its members? Do you support members by providing information, focus and support? If you do, and you are a Professional Member of the World Polyamory Association, fill out this section and include your promotional material and curriculum. With board approval you’ll receive your beautiful certificate and be included on our web site as a Certified Professional Member.

Your Name:  

Name of School/ Institute/Center:  

Your Title:  

Year founded: 

Number of years you have been involved:  

25 Word statement promoting your business:

 

$50 Specialty Certification      Wall Certificate $25 



FELLOW

To Qualify as a Fellow, you must be a current Professional Member of the World Polyamory Association and been active in your chosen field for over five years. Send us proof of your experience (a copy of your business license; dated advertising flyer) and we will send you our written exam. Upon board approval, you'll receive your well deserved recognition and beautiful certificate and be included on our web site as a Certified Professional Member.

Name: 
 

Field: 

Date practice began:


Number of years in practice:


25 Word statement describing your experience:


$50 Specialty Certification      Wall Certificate $25 

INSTRUCTOR/ TRAINER/ COACH

If you are a Professional Member of the World Polyamory Association and train and certify practitioners in your field, instruct in a training school, or offer classes, you may qualify as one of our Authorized Instructors. Fill in this section and include an outline of your course and instruction materials. Upon board approval you ll receive your beautiful certificate and be included on our web site as a Certified Professional Member.

Name: 


Field: 

Where taught/trained/coached: 
 

Number of years: 

25 Word statement promoting your business:


$50 Specialty Certification      Wall Certificate $25 


SCHOOL/ INSTITUTE/ CENTER

Do you have a training school in your field? Do you offer correspondence or mail order classes? Do you give seminars and lectures? If you do, and you are a Professional Member of the World Polyamory Association, fill out this section and include your promotional material and curriculum. With board approval you'll receive your beautiful certificate and be included on our web site as a Certified Professional Member.

 Name: 

Name of School/ Institute/ Center

Your Title:


Year founded:


Number of years you've been involved:

25 Word statement promoting your business:
 

$50 Specialty Certification      Wall Certificate $25 

RESEARCHER

If you are a Professional Member of the World Polyamory Association and conduct research in your chosen field, you may qualify as a Board Recognized Researcher. Fill in this section and include an outline of your research project and any current findings. Upon board approval you'll receive your beautiful certificate and be included on our web site as a Certified Professional Member.

Name:  


Field:

Year research began:


Number of years you've been involved in your research:

Title of Project: Goal:
 

$50 Specialty Certification      Wall Certificate $25 

WRITER/ JOURNALIST

If you are a Professional Member of the World Polyamory Association and write books, columns or articles in your chosen field, you may qualify as a Board Recognized Writer. Fill in this section and return it with a sample copy of your work or work in progress.  Upon board approval you'll receive your beautiful certificate and be included on our web site as a Certified Professional Member.

Name:


Field:


Year began writing:


Number of years you've been involved in writing:

Title (or working title) of Book(s), or Column(s) Published by:
(use additional email if necessary and send to WorldPolyamory@aol.com)
 

$50 Specialty Certification      Wall Certificate $25 

STAGE/ MEDIA PERSONALITY

If you are a Professional Member of the World Polyamory Association and regularly appear on Radio, Internet Radio, Television, Video, or Movies in your chosen field, you may qualify as a Board Recognized Media Personality. Fill in this section and send us an audio or video sample copy of your work. All audios or videos will not be returned. Upon board approval you'll receive your beautiful certificate and be included on our web site as a Certified Professional Member.

Name:


Field:


Year started:


Number of years you've been involved in media:

Nature of Media Work:
 

List appearances:
 

25 Word statement promoting your business:
 

$50 Specialty Certification      Wall Certificate $25 

PROFESSIONAL SPEAKER

If you are a Professional Member of the World Polyamory Association and a platform speaker or seminar leader in your chosen field, you may qualify as a Board Recognized Professional Speaker Fill in this section and send us an audio or video sample copy of your work. All audios or videos will not be returned. Upon board approval you'll receive your beautiful certificate and be included on our web site as a Certified Professional Member.

Name: 

Field:


Year you began speaking:


Number of years you've been involved in speaking professionally:

Nature of Media Work:
 

List appearances:
 

25 Word statement promoting your business:
 

$50 Specialty Certification      Wall Certificate $25 

Whatever your area of expertise, with proof of your training or experience, your certificate can underscore your chosen focus. Check all the boxes that apply to you.

Select any of the following Professional Focus options that apply:  (not in alphabetical order)

Actor  Brain Trainer Energy Balancer  Hypno-Healer
Acupuncture   Breath Worker  Entertainer  Hypno-Minister 
Addiction Counselor Business Consultant Existential Analyst  Hypno-Nurse 
Addiction Counselor  Carpenter Feng Shui Specialist  Hypno-Researcher 
Anesthesiologist      Chiropractor  Film Maker Hypnotist 
Animal Communicator  Clinical Hypnotherapist  Forensic Hypnotist Hypnotherapist
Anthropologist Colon Therapist Freudian Psychoanalyst Instructor 
Architect  Color Therapist  Fung Shei  Iridology  
Aromatherapist Computer Graphic Artist  Gestalt Therapist Jin Shin Jutsu
Artist    Computer Guru Graphic Artist  Joy Therapist 
Astrologer Counselor   Herbalist Jungian Analyst 
Astronomer Corporate Trainer Healer  Life Coach 
Aura Intuitive Cranial Sacral  Health Practitioner Lightworker 
Author  Crystal Healer  Holotropic Breathworker Non-Violent Communications Facilitator
Ayurveda Specialist  Daka  Homeopathic Physician Marriage & Family Counselor
Behavioral Counselor  Dakini Humanistic Psychologist  Marriage Officiant   
Biofeedback Specialist  Dental Hygienist  Huna Teacher Master Hypnotist 
Birther  Dental Hypnotherapy Hypno-Anesthesiologist Media Personality
Blood Reader Dentist Hypno-Birther  Medical Doctor 
Body Worker  Designer  Hypno-Counselor  Medical Hypnotherapist 
Metaphysician  Medical Intuitive  Motivational Speaker  Motivator 
Massage Therapist  Musician Naturopathic Physician Neuro-Hypnotist 
Neurolinguistic Psyhchologist  Nurse  Numerologist  Occupational Therapist  
Pastoral Hypnotist  Pastoral Hypnotist  Photographer  Physician 
Poet  Polarity Therapist  Professional Speaker  Professional Speaker 
Psychiatrist  Pscyhological Consultant Psychologist  Psychologist 
Psychic Reader  Rebirther  Reflexology/Vitaflex  Reiki 
Relationship Counselor  Reporter  Researcher  Rolpher 
Sales and Marketing Consultant  Scientist   Shaman  Shiatzu Healer 
Singer    Sound/Toning Therapist Spirit Releasement Therapist  Spiritual Counselor 
Spiritual Emergency Therapist  Spiritual Leader/Minister/Priest/Guru  Sports Hypnotherapy Stage Hypnotist
Stress Manager  Success Coach Success Trainer Tarot Card Reader
Tai Chi Teacher  Tantra Educator   Tantra Practitioner  Tantrica
Trance Channel  Transpersonal Hypnotist Transpersonal Hypnotherapist  UFO Researcher
Videographer  Voice Dialogue Facilitator Watsu Healer  Web Designer  
Weight Loss Specialist  Writer   Yoga Instructor 

Other:


PAY AND SIGN - AS LISTED WITH YOUR CREDIT CARD COMPANY

Name:


Phone:

Home address: 

City: State: Zip:

PAYMENT TOTAL

Card Number:   Exp Date: 

Cardholders Signature:  

CODE OF ETHICS:

Each member must agree to abide by the  World Polyamory Association's Code of Ethics. In order to complete your application and receive your certificate for your wall and to be listed on our web site, please read, sign and date, then return all forms to the address below.

1. Each member honors the holistic well being of the client.
2. Members shall work together to broaden and improve the use of healing, counseling, coaching and mind and consciousness modalities.
3. Members shall observe the professional and ethical standards of the society and their personal and professional affiliations.
4. Members shall use positive programming and related techniques in their respective areas of professional competence.
5. In providing and representing services, members shall not overstate credentials or make unsubstantiated claims.
6. Members must maintain the confidentiality and privacy of information shared during client sessions.

By clicking HERE I agree to the World Polyamory Association Code of Ethics: 

If you have documentation that we need to review, print fill out and this form, sign it and mail it to the address below along with copies of your documentation. You may use extra paper to describe what you do and list your associations and recognitions.  Professional members who are approved are listed in the WPA Certified Professional Directory as well as the regular Professional Member's Directory.  .  

Print Name: ____________________________________________

Sign Name:_____________________________________________    Date: ___________________

Send all forms and documentation to:

World Polyamory Association
1371 Malaihi Road
Wailuku, Maui, HI 96793
808-244-4103
WorldPolyamory@aol.com

Approval make take up to 4-6 weeks.



 

CANCELLATION POLICY

No Refunds on Membership Fees

Refund Policy for Conferences & Events:
90 days or more - Refund fee is 25% of price
60 days or more - Refund fee is 50% of price
31-59 days - Refund fee is 75% of price
30 days or less - Refund fee is 100% of price
5 days or less - no credits or refunds

To Cancel send your request in writing to:
WorldPolyamory@aol.com or write to

World Polyamory Association
1371 Malaihi Road
Wailuku, Hawaii 96793
Be sure to include your name, address, email and phone.

After you register, and if you cannot attend the Conference or Event, you may:
1. Send a substitute or
2. Receive a credit memo to be applied in one year (12 months) toward another WPA event.

Returned checks will be charged a $25 bank service fee.

Copyright © 2004 [WorldPolyamoryAssociation]. All rights reserved.
Revised: July 22, 2011