Title: __________

Name: ________________________________________

Date of Birth:
dd/mm/yyyy ____________

Sex:
M: F: __________

House name or number and street:_____________________________________________________________

_______________________________________________________________________________________

Town& County:___________________________________________________________________________

Postcode:________________________

Telephone:_______________________________________

Email Address:____________________________________________________________________________

Website URL:_____________________________________________________________________________

Membership Type:
(please tick which is required)
South Yorkshire Healers Full
South Yorkshire Healers Associate
South Yorkshire Healers Couple Membership
Yorkshire Mediums Full
Yorkshire Mediums Associate
Yorkshire Mediums Couple Membership
Joint Yorkshire Mediums and South Yorkshire Healers
Joint Couple Membership Yorkshire Mediums and SYH
Sheffield Paranormal Investigations Full
Sheffield Paranormal Investigations Associate

Member of Other Group or Organisation?:
No: Yes: If yes state which: ___________________________________________________________________

________________________________________________________________________________________

Qualifications (copies of these will be required):____________________________________________________

If you are a Medium or Psychic please supply 3 references preferably from churches or centres where you have worked in this capacity or from clients you have given a paid consultation to ( not family or friends - references will be checked).

Reference 1:

Reference 2:

Reference 3:

Other Relevant Information:

Have you ever had a criminal conviction?

Yes: No: ______________

If you answered yes, please give details:

Do you currently hold a Professional Indemnity insurance?

Yes: No: __________________

Have you ever been refused insurance cover?

Yes: No: ___________________

If you answered yes to either of the above, please give details:

Criminal Records Form - Please fill in Form 2 below, sign and return to us by post.

Place of Birth:_________________________________________________________

Are you a British citizen?:

Yes: No: If "No" please give details. ___________

Are you interested in any of the following? (Please tick all that apply) :

Comments:

Do you want to place an add on our websites? (Full members only):

No: Yes: If yes please email us with details. _______________

Signed:_______________________________________ Date: _________________

Please send your photographs, proof of qualifications, copies of any currently held CRB disclosures together with the three completed and signed forms to:

Brenda Diskin, Secretary SYH, 194 Lindsay Avenue, Old Parson Cross, Sheffield, South Yorkshire, S5 7SG (or e-mail to sacredearth2@hotmail.com)

Please DO NOT send any cheques to cover insurance payable to me please contact me first.

**SYH or it's founders reserve the right to refuse or revoke membership at anytime without prior warning, if deemed necessary.

Form 2

SOUTH YORKSHIRE HEALERS

NO CLAIMS DECLARATION
NOTE:
It is a requirement of Insurance cover that this Declaration Form be returned to South Yorkshire Healers duly completed

Please circle the answers to the questions below:

1. Have you ever been convicted of any criminal offence, other than
Motoring, or are there any prosecutions pending? Yes  No

2. Has any insurer ever cancelled, declined or refused to renew, or
accepted the risk at special terms? Yes  No

3. Have you had any claims, or incidents, which could give rise to a claim under the policy
involving negligence, error or omission, or are you aware of any circumstances which may
revert to such a claim or suit being made against you? Yes  No

4. Would you have any objections, should the need arise, to having a police CRB
check or joining a Vetting and Barring Scheme? Yes  No (If you already have a CRB disclosure-please send us a copy)

______________________________________________
If the answer to any of the above is "yes" please give information in the space provided (continue on a separate sheet of paper if necessary) do not sign the declaration below.

__________________________________________

I confirm that I have read, and understood, the above. Yes  No

_______________________________________________

I confirm the answers I have given above are true and that I have not withheld any material fact.

I am aware of no claims, suits or any circumstances which could reasonably lead to a claim being made, or action initiated, against me.

Signed:_______________________________________ Date: _________________

Title:______ Surname:______________________ First Name(s):______________

Address:_____________________________________________________________

__________________________________________ Post Code: ________________

Phone No: ___________________ Email: ________________________________

Please return this form with your application for membership to:
Brenda Diskin, Secretary SYH, 194 Lindsay Avenue, Sheffield, South Yorkshire, S5 7SG