REGISTRATION FORM: RK1
 

Application for registration as:
KINDERKINETICIST / ASSISTANT KINDERKINETICIST

An amount of R1250 must be deposited / made out to:
SAPIK – Account number: 9305430937, Branch Code: 632005, ABSA, Tom Street, Potchefstroom.
Reference: Name, surname, RK1.
A copy of the deposit slip must accompany the completed form and be e-mailed to the above email
address or faxed to (018) 299 1825 or hand delivered to the office.


The following registration form must be completed in full. Take note that SAQA require specific
information each year. In order to obtain that information, you need to complete all sections of this
form. If this document is incomplete, your registration will not be successful and a fine will be
applicable after March of each year

  * Fields are mandatory
  * PERSONAL INFORMATION
     
  Last name
  Initial
  Title
  First name
  Middle
  Maiden name
  ID/Passport number
  Nationality
  Home language
  Ethnic group
  Gender
     
  * Physical Address
   
 
   
  * Postal Address
   
 
   
  *
     
  Province
  Email address
     
  * Contact numbers
     
  Work
  Cellphone
     
  * Do you have any disability (If yes, elaborate)?
   
 
   
  * Rate yourself according to the following: Indicate the correct number next to each question. 1. No difficulty; 2. Some difficulty; 3. A lot of difficulty; 4. Cannot do at all; 5. Cannot be determined, 6. May be part of multiple difficulties, 7. May have difficulty, 8. Former difficulty – none now. For example. Seeing = 2
     
  Seeing:
  Hearing:
  Communicating:
  Walking:
  Remembering:
  Self-care:
     
  * OCCUPATIONAL INFORMATION
     
 
     
  *
     
  Kinderkineticist
  Assistant Kinderkineticist
  Other (Please specify below)
   
 
   
 
   
  *
     
  SAPIK Registration number
  Institution of Training
  Honors year
     
  * EMPLOYMENT INFORMATION
     
  Employer (Owner of a practice)
  Working at a Training Institution
  Employee (Working at a practice)
  Appointed at a school
     
  * PRACTICE INFORMATION
     
  Practice/school name
  Practice/school address
  Location
     
  * Services: (Please list all programs offered if applicable)
   
 
   
  * Who works at the practice? (Please list all. If applicable)
   
 
   
   
 

*Please attach a copy of the practice/school logo in vector format for our website.
*If any information changes, please contact SAPIK directly.

   
   
 

TRANSFORMATION QUESTIONNAIRE

   
  * Do you think SAPIK requires racial and gender transformation?
     
  Yes
  No
     
  * Please provide ideas on how to improve SAPIKS transformation status of all races and gender to apply for Kinderkinetics.
   
 
   
  * How can Universities play a role in transformation?
   
 
   
  * How can you as a member assist SAPIK’s transformation plan based on gender and race?
   
 
   
   
 

DECLARATION:
I, hereby apply to be registered as Kinderkineticist / Assistant Kinderkineticist at SAPIK and declare that all information provided (including copies) is completed and correct. I also declare that I have read and understand the updated Ethical Guidelines of SAPIK, and that I agree to abide by these rules and regulations. I accept responsibility to keep updated with any changes made regarding the guidelines.

   
  * I agree
     
  Yes
   
  * Date
 
   
   
 

Please attach:
- Proof of payment
- Copy of the practice/school logo in vector format for our website

   
  * Upload proof of payment here
 
   
  * Upload your copy of the practice/school logo here
 
   
 


 
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