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FACILITATED PROGRAM IN BUSINESS CONTEXT

Do you have your:
1. Business Insurance 2. List of the scheduled program dates
Ready to email to support this registration?

CHIP Program Registration

Scheduled CHIP Commencement Date *

Business Number or Licence

First Information Session Date *

Second Information Session Date *

Name of Hosting Facilitator *

Organisation *

Billing Address *

Suburb and Postcode *

Country *

Facilitators Phone Number *

Facilitators Email *

Type of Program *

Online

In-Person

Hybrid (online and in-person)

Resources Required *

CHIP Kits

CHIP Hub

CHIP Drive (USB)

If you have a CHIP Drive, what is the expiry date?

CHIP Venue *

Venue Address *

Suburb and Postcode *

Country *

Certified CHIP Facilitators Assisting in the Program

Name (Assistant 1)

Name (Assistant 2)

Name (Assistant 3)

Attach a separate document if needed

Is your program limited to a certain demographic? *

Yes

Please describe

Please provide details. Eg: retirees, young mums, unemployed, people with high blood sugar etc.

Minimum participant number allowed? *

Maximum participant number allowed? *

Do you have business insurance to cover this program? *

Please provide details

Please indicate your anticipated charges for the program

Level 1 *

(Includes Attendance, CHIP Kit/CHIP Hub, Bloods, Program Expenses)

Level 2 *

(Includes Attendance, Bloods, Program Expenses)

Level 3 *

(Includes Attendance, Program Expenses)

Level 4 *

(Attendance (FREE), Includes Bloods, Program Expenses)

Level 5 *

Attendance (FREE) No inclusions

Today's Date *

Acceptance *

I understand I am unable to allow any resident of the European Union to join my program.

My business insurance covers the CHIP program. I have provided a copy for your records

I have completed a list of scheduled dates for my upcoming program.

Thank you for your message. It has been sent.

There was an error trying to send your message. Please try again later.

Please email the following to support this registration

1. Business Insurance 2. List of scheduled program dates

List of scheduled program dates. Forms available for download in MSWord or PDF format.
MSWord doc | PDF doc

Return Completed Form LMI CHIP 4 weeks prior to the program commencing

ask@chiphealth.com.au
Phone +61 (02) 9847 3367

CONTACT US

LMI CHIP
Suite 2, Level 11,
157 Walker Street,
North Sydney NSW 2060

ABN 70 145 723 119

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