Privacy Act (PIPEDA) Permission Form

In order to publish your information on our Website, please click on the following link, print, sign the PIPEDA permission form and mail it to T.T.N.Q. at the address indicated on the document.
  
                         201501 PIPEDA (ADEPIP) Form 
 
PRIVACY ACT (PIPEDA) PERMISSION FORM
“ Personal Information Protection and Electronic Documents Act ” 
 
In order to conform to the Personal Information Protection and Electronic Documents Act (PIPEDA), your authorization is required before posting information on the Therapeutic Touch Network of Quebec (TTNQ) website and/or other publicity.  Please complete all sections that apply to you and sign your authorization for the (TTNQ) website and/or other publicity.
 
PLEASE PRINT CLEARLY :
 
Name : _________________________________________
Address : ____________________________________________
 City : __________  Prov. _________  Postal Code : ___________
 Tel.: ______________________  Email : ___________________
Website : ____________________________________________
 
I authorize the Therapeutic Touch Network of Quebec (TTNQ) to list my name and my contact information on their website and/or other publicity.
 
I understand and accept that the Therapeutic Touch Network of Quebec (TTNQ) is not responsible for any consequences to me, my family, or to my business resulting from my listing on their website and/or other publicity.
 
Signature : _________________________        Date :  ___ /___ /____
                                                                                                                     D  /   M  /    Y
 
FOR RECOGNIZED TEACHERS ONLY
(Therapeutic Touch levels)
 
I would like my name, the levels I teach and the following contact information to be listed on TTNQ website and/or other publicity :
 
Level :  (  ) 1,  (  ) 2,  (  )  3     Teacher : _________________________
Location :  (City only) ____________________________________
 
FOR GROUP PRACTICE LEADERS ONLY
 
I would like my Practice Group to be listed on TTNQ Website and/or other publicity :
 
(   )  Primary Contact : ________________________________
(   )  Secondary Contact : _______________________________
City : ______________________________________
 
Please mail to :Therapeutic Touch Network of Quebec, P.O. Box 46054, Pointe-Claire, Québec, H9R 5R4