Grandfather Provision Application Form What you are applying for:Type of Membership: Professional Membership: Grandfather Provision The grandfather provision will apply during the interim period from January 2023 to December 2026. Refer to the Membership tab/Membership Overview for definitions. Accreditation: I am applying for membership to become a Certified Medical Tai Chi & Qigong Instructor (CMTQI). Designation of Health Promotion in the General category.Profile DetailsFirst name/Given Name *Last name/Family Name *Email Address *Date of Birth (optional)Phone *.Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabwe..Gender *This field cannot be emptyMaleFemaleOtherFor Other Gender, enter details.Details of Training and QualificationsDo you have experience of teaching Tai Chi/Qigong for a minimum of three years full-time or five years part-time and are currently teaching Tai Chi/Qigong? *This field cannot be emptyYesNo..How many total HOURS and YEARS have you taught Tai Chi and/or Qigong? (please estimate from all sources.) (eg xxx hours per year / xx years) *What is the main style of Tai Chi and/or Qigong that you learned and teach?* Specialized Styles (check all that apply) *Chen StyleSun StyleYang StyleWu StyleWu Hao StyleBuddhist GigongDaoist QigongMedical QigongMartial QigongOtherIf Other, please specifyReferencesReference 1 - Name *Reference 1 - Phone *Reference 1 - Email Address *Reference 2 - Name *Reference 2 - Phone *Reference 2 - Email Address *Reference 3 - Name *Reference 3 - Phone *Reference 3 - Email Address *Do you have other health-related licenses and/or certifications? If so, please describe.Assessment of TQ Skills and CompetencySelect from one of the folllowing 3 OPTIONS for Assessment of TQ Skills and Competency *This field cannot be emptyOPTION 1 - I will attend the iMTQA workshop/conference and demonstrate my TQ skills to the accreditation committee.OPTION 2 - I attended the iMTQA workshop/ conference, demonstrated my TQ skills and been certified by the accreditation committee.OPTION 3 - I attached my TQ video file for assessment.....Assessment of TQ Skills and Competency Applications can either attend the iMTQA workshop/conference and demonstrate their TQ skills to the accreditation committee OR Provide a 4-6 minute video for assessment. Requirements for video submission: iMTQA holds the right to request that an application for membership be accompanied by video evidence demonstrating an applicant’s skills in Tai Chi and/or Qigong. An evaluation of each video will be undertaken by the Accreditation Committee, whose decision whether to accept or reject the application will be final. This assessment will particularly apply to those applications for membership where a request is made by an applicant for “grandfathering” provisions to apply. Applicants can register and submit their videos supporting their application for membership via the iMTQA website (www.imtqa.org) or email (membership@imtqa.org). At the time of submitting a video, the applicant must also submit their “Video Registration Details” via email which will include: Requirements for the video: Each video demonstration will be 4 to 6 minutes in duration. Video demonstrations of a longer duration than 6 minutes will only have the content of the video up to the 6-minute timeframe considered. Separate video demonstrations will be required for Tai Chi and Qigong. The video may be recorded using a camera or smartphone and has to be submitted in standard video formats of either MPG, MPEG, AVI, MP4 or MOV only. The recommended video resolution is 1080p: 1920 x 1080. The video must be clear, stable and smooth, recorded in a landscape orientation. Video editing including acceleration and video effects are not permitted. Lighting must be adequate for members of the iMTQA Accreditation Committee to easily view the demonstration. The full body of the applicant must fit into the video frame throughout the entire demonstration. If OPTION 3 - Please provide the URL/Web link to your video e.g. YouTube, Vimeo or OtherParticipate in the iMTQA workshop/ conference and demonstrate your TQ skills to the accreditation committee members. (If you have already participated, provide the details)If you have not yet participated, do you undertake to do so within 6 months?YesNoSupporting DocumentsReference Letter 1 (file upload) *Choose FileNo file chosenDelete uploaded fileThree or more recommendation letters from your students and your previous Tai Chi/ Qigong teachers/mastersReference Letter 2 (file upload) *Choose FileNo file chosenDelete uploaded fileThree or more recommendation letters from your students and your previous Tai Chi/ Qigong teachers/mastersReference Letter 3 (file upload) *Choose FileNo file chosenDelete uploaded fileThree or more recommendation letters from your students and your previous Tai Chi/ Qigong teachers/mastersCopy of Valid ID 1 (file upload) *Choose FileNo file chosenDelete uploaded filee.g. Government issued ID such as drivers license, passportCopy of Valid ID 2 (file upload) *Choose FileNo file chosenDelete uploaded filee.g. Government issued ID such as drivers license, passportHigh quality passport sized photo (file upload) *Choose FileNo file chosenDelete uploaded fileLetter of intent to undertake basic education in clinical aspects approved by the iMTQA (see sample) *Choose FileNo file chosenDelete uploaded fileProvide evidence of completion of the course “How to deliver Tai Chi/ Qigong safely (more than 2 hours program)” or have made arrangements to undertake the course within 6 months of applying for membership. *Choose FileNo file chosenDelete uploaded file.Police History or Criminal Check CertificationDo you have any criminal history in the US or overseas? *This field cannot be emptyNoYesIf YES, you must attach a signed and dated written statement with details of your police clearance or criminal history in the US and overseas and an explanation of the circumstances.Choose FileNo file chosenDelete uploaded file.Declaration and AgreementDeclaration and Agreement TermsThe information given on this form is true and correct. I make the following declarations: • I declare that I will abide by the IMTQA Code of Ethics and any applicable rules, codes and regulations. • I declare that I will abide by all applicable health fund provider terms and conditions. • I declare that I am not currently under criminal investigation. • I declare that I have not had any licensure board or professional association ever discipline me. • I declare that I have not had my hospital privileges, license, certification, or registration suspended or revoked by any licensure board, professional association or healthcare agency. • I declare that I have never had my malpractice insurance revoked. • I understand that I must pay all my subscriptions and other monies due to iMTQA until I resign my membership. If you cannot make this declaration due to a specific situation, please address the issue in an explanatory statement.Please Type Your Name *Date Signed *...Mandatory Fiields ReminderPLEASE MAKE SURE ALL MANDATORY FIELDS ARE FILLED IN TO AVOID SUBMISSION ISSUES.PaymentGrandfather Provision Application FeeYour application will not proceed without your application fee. You may also pay first year membership fees now, or wait until your application has been processed. Initial Application Fee: US $100.00 (non-refundable) Professional Annual Membership Fee: US $295.00 (refundable if application does not meet the eligibility criteria) Total Payment: US $395.00 (Initial application fees plus Professional Annual membership fees) Submit ApplicationSave as Draft Note you can “Save as Draft” and come back later.
