Pre-registration of a learner

HYPNOSE ET MOUVEMENTS ALTERNATIFS - SESSION 2 - from February 2, 2022 to February 3, 2022

Vous pouvez préinscrire un stagiaire à la formation grâce à ce formulaire. Merci de rentrer un maximum d'informations pour simplifier le travail d'enregistrement. Vous pouvez laisser un message complémentaire dans la partie 'Notes libres'.

General information

Learner's photo

JPG, PNG or WebP, ≤ 500Ko

Honorific

First name*

Last name* Email* Date of birth*

Birth name

Nationality

Postcode of place of birth

Address*

Postcode*

City*

Country

Phone*

Secondary phone

Language in the Learners' Portal

Status

Company*

Profession*

Company registration number*

DPC fields

ADELI NO.

RPPS NO.

Main exercise (> 50%)*

Other

Free notes

Information for funding agencies

Disabled worker recognition

Fields marked with * are mandatory.

The data collected in this form is processed by Institut Montpelliérain d'Hypnose Ericksonienne Médicale in order to manage your registration on the site. To find out more about the management of your personal data and to exercise your rights, we invite you to read our privacy policy