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Professional - Registration Form

Title

First name*

Last name*

E-mail*

Password*

Confirm Password*

Mobile number*

Profession*

HPCSA/SACSSP/ASCHP Reg. No.*

Registered qualifications*

BHF Reg. No.

Rate Filter*

Rate per hour (R)*

Discounted Matching Sessions*

YesNo

Referral Source

ID/Passport number*

Copy of ID/Passport*

Upload

Headroom's Terms of Use*

I have read and accept Headroom's Privacy Policy, Acceptable Use Policy, Professional Services Agreement and the Headroom Pricing Schedule.

Headroom Service Level*

Ethics and Code of Conduct*

I confirm my compliance with the Ethical Guidelines and the Codes of Practice of the Professional Body I belong to (HPCSA/SACSSP/ASCHP) and/or any other rules and regulations applicable by virtue of my professional memberships listed on my Headroom profile.

Certificate of Status*

I acknowledge that Headroom may, at its sole discretion, request my Certificate of Status from the relevant Professional Body.

Calendar Sync*

I here-by give permission to Headroom to synchronise my Calendar for the duration of my listing on its platform. This is limited to busy/free times visibility.

Social Media *

I hereby grant permission to Headroom to promote my profile via social media in line with the HPCSA Ethical Guidelines on Social Media.

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Professional - Registration Form

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