/ Application for Professional Membership

Full Professional Membership ¨ £68

Affiliate Professional Membership ¨ £58

Student Professional Membership ¨ £25 * for those attending BDA accredited courses

If you are resident overseas, please add £15 to membership fees ¨

Personal details:

Title Forename: / Surname:
Address: / Landline:
Address: / Mobile:
Town/City: / Preferred Email address :
County:
Post Code: / Country if not in UK:
Please highlight your BDA awarded specialist SpLD accreditation
Certificate Number / Certificate Number:
AMBDA / APC
ATS / TPC
APS
ATS FE/HE
BDA Accredited Course attended and dates
Professional Student Membership BDA Accredited Course attending
Have you completed BDA approved CPD in the last 3 years?
If yes, please give the date on your CPD certificate
Affiliate Membership, please indicate which Affiliated Profession you are a member of and include evidence, HCPC Number
Educational Psychologist / Speech & Language Therapist / Occupational Therapist
Clinical Psychologist / Chartered Psychologist

With Professional Membership you may also purchase:

Dyslexia Handbook / £10.00
Dyslexia Journal / £55.00 (4 copies per annum)
Tailored Professional Indemnity Insurance is available through the Alan Boswell Group at
http://www.alanboswell.com/business-insurance/teacher-insurance/bda/

Data Protection Act 1998

The information you provide on this form will be used by the BDA to process your application for Professional Membership and will be kept on the BDA’s Professional Membership database. We will not pass your details to third parties.

From time to time we would also like to send you information about the BDA’s other services, offers, activities and appeals.
If you would like to receive this information please tick here ¨

Declaration

Applying for and becoming a Professional Member of the BDA will indicate that you have read and agreed to abide by the BDA Code of Ethics and Conduct. These can be accessed at http://www.bdadyslexia.org.uk/common/ckeditor/filemanager/userfiles/Services/Practising_Certificates/BDA_Code_fo_Ethics_0116.pdf

o  I have read the Data Protection Act statement above.

o  I understand that Professional Membership fees must be received in full before the application is processed and that all fees are non refundable.

o  I have read and agree to abide by the BDA Code of Ethics.

o  i understand that I must carry Professional Indemnity Insurance to be listed on the BDA List of Specialist Tutors and Assessors

o  I understand that I must maintain appropriate CPD throughout my membership period to be listed on the BDA List of Specialist Tutors and Assessors

o  I undertake to adhere to decisions made by the BDA Accreditation Board.

o  I understand that BDA Membership is paid annually by direct debit.

Signed by hand: / Date:

Send your completed form and direct debitto:

Professional Membership, BDA, 6a Bracknell Beeches, Old Bracknell Lane West, Bracknell RG12 7BW or email to

Please fill in the whole form including official use box using a ball point pen and send it to: /
Service user number
Finance
British Dyslexia Association
6a Bracknell Beeches
Old Bracknell Lane
Bracknell
RG12 7BW / 8 / 3 / 8 / 3 / 2 / 7
FOR RSM 2000 Ltd re British Dyslexia Association OFFICIAL USE ONLY
This is not part of the instruction to your bank or building society.
Name(s) of account holder(s)
Bank/building society account number
Branch sort code / Instruction to your bank or building society
Please pay RSM 2000 Ltd re British Dyslexia Association Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with RSM 2000 Ltd re British Dyslexia Association and, if so, details will be passed electronically to my bank/building society.
Name and full postal address of your bank or building society
To: The Manager / Bank/building society
Address / Signature(s)
Postcode / Date
Reference
B / D / A / P / R / O / F / E / S / S / I / O / N / A / L
Banks and building societies may not accept Direct Debit Instructions for some types of account

This guarantee should be detached and retained by the payer.

The
Direct Debit
Guarantee
·  This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits
·  If there are any changes to the amount, date or frequency of your Direct Debit RSM 2000 Ltd re British Dyslexia Association will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request RSM 2000 Ltd re British Dyslexia Association to collect a payment, confirmation of the amount and date will be given to you at the time of the request.
·  If an error is made in the payment of your Direct Debit, by RSM 2000 Ltd re British Dyslexia Association or your bank or building society you are entitled to a full and immediate refund of the amount paid from your bank or building society
– If you receive a refund you are not entitled to, you must pay it back when RSM 2000 Ltd re British Dyslexia Association asks you to
·  You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.

BDA. February 2107

Company No. 1830587; Charity No. 289243. Page 3 of 3