Download registration form

International Seminar
“Trauma and the body in Psychotherapy:
The Clinical Treatments”
Roma - 10/11 June 2017
REGISTRATION FORM
(fill up the 2 sheets and send them to: [email protected])
(Fill the form in Block Letters)
Personal Data
Surname
Name
Place and Date of Birth
Address
Postal Code
Phone
City
Province
Cell Phone
E-mail
Profession
Professional Order or Association
dellaprovinciaoRegione
Province where you mainly work
Tax Code:
Vat number:
Privacy Policy Statements: 1. Personal data given to Gestalt Therapy Institute -H.C.C. Kairòs srl will be treated, according to
the institutional aims of the Institute invoking its competition law powers, in order to fulfill Administrative financial and
insurance tasks. Respect of the legislation on protection of personal data (Legislative Decree 196/03) and informed that
personal data provided by the parties concerned through the various collection channels, directly or indirectly managed by
the Owner . 2. The treatment will be conducted through computer and paper format.
3. The conferring of the data is therefore obligatory is necessary for the fulfillment of institutional and contractual duties of
the Gestalt Instition. The eventual failure of obtaining the consent could implicate the total or partial failure of the
performance of the contract.. 4.The Institute is authorized /allowed to transmit the personal data to public actors, in
accordance with the provisions of Law and to the regulations for the fulfillment of the institutional aims. the
communication will also be directed to those public and private actors necessary to the proper fulfillment of the goals
specified/mentioned in the first point and, moreover, to public and private actors in case of possible contacts for job
opportunities. The institute is also authorized to treat and communicate personal data with the core of commercial
promotions and market analysis, with the aim of improving the service we offer.. 5. At any time, it is possible to exercise
his rights to the owner of the treatment in compliance with articles 7 and 13 of the Legislative Decree 196/2003, which
claims the right to have the proof of the existence of the data at any time and also the right to be informed about the
content, prove the exactitude or ask for the integration or the update, or the rectification, the right to request the
cancellation. It is possible to transform it in anonymous form or to block the data treated in infringement of law. He also
has the right to object the treatment, at any time for every reason.
6. The owner of the Treatment is the Gestalt Therapy Institute – H.C.C. Kairòs S.r.l. with administrative address in Ragusa,
Via Virgilio 10, represented by the legal pro tempore resident at the Institute address.
That having been said, the undersigned freely express, in compliance with articles 23 and 26 of the Legislative Decree
196/2003, his own approval so that the Gestalt Therapy Institute – H.C.C. KAIRòS proceed with the treatment, the
communication and to the circulation of the sensitive personal data for the aims mentioned in the policy statements.
Place and Date
Signature
/
/2017
Hereby, I undertake to deposit, not later than 1/06/2017, the overall amount of:
 Euro 210 (including VAT) for the registration to the seminar of 10th and 11th June
2017
 Euro 150 (including VAT) for the registration to the seminar of 10th and 11th June
2017 realized not later than the 1st March 2017.
 Euro 120 (including VAT) for the registration to the seminar of 10th and 11th June 2017
for those who benefit from the discount reserved to students specializing in
Psychotherapy and for those graduating in Medical and Psychology.
The payment of the amount can be realized through a bank transfer made out to:
Istituto di Gestalt Therapy hcc Kairòs srl - c/o la
Banca Agricola Popolare di Ragusa agenzia n.4 Ragusa,Via Ducezio n.27/B
IBAN:IT77Q0503617004CC0041071439
Place and Date
Signature
/
/2017