| 1. | Name ______________________________________ Date _____ / _____ / _____ |
| 2. | Mailing Address ____________________________________________________________________ |
| City ___________________________ State _____________ Zip Code _________ | |
| 3. | Telephone (H) ________________ (W) __________________ Soc. Security # _____ - _____ - _____ |
| 4. | Birthdate ____ / ____ / ____ Age ____ Drivers Lic.# ___________________ Issuing State ___ |
| 5. | Sex:
Male
Female
|
| *6. |
High School No. of
Years ___________ Grad. Year ___________ |
| Please enclose a copy (not original) of diploma or certificate. | |
| *7. | Are
you in good health at present?
Yes
No |
| If no, what is your present condition? ______________________________________________________ | |
| Please enclose a letter from a physician (must be M.D. or D.O.) concerning physical condition | |
| and present state of health. | |
| 8. | Have
you had or do you presently have a substance abuse problem?
Yes
No |
| 9. | Have
you ever been convicted of a crime not including traffic violations?
Yes
No |
| 10. | Who should be notified in case of emergency? |
| Name ______________________ Relationship ______________ Telephone ______________ | |
| 11. | Class
Start Date: ______ / ______ / ______
Day
Night |
| 12. | How did you hear about our school of massage? ____________________________________ |
| *13. | Please enclose two standard passport size photos (2" x 2") with this application. |
| 14. | Have
you been to the school for an interview?
Yes
No< |
| * Note: Items 6, 7 and 13 can be done at time of enrollment. | |
| I certify that the information above is true. I understand that it will be held in strictest confidence and will only be used to determine the degree to which I may benefit from training. | |
| Date ______ / ______ / ______ Signature _______________________________ |