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Do you have any learning challenges? YesNo

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Are you under medical supervision? YesNo

If yes, please explain:

Are you currently taking any medications? YesNo

If yes, please explain:

YesNo Do you have any communicable diseases?

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Emergency Contact

Name:

Relationship:

Home Phone:

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Name of High School:

Year Completed:

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If you did not complete high school, did you receive a GED? YesNo

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Reference

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Phone:

Email Address:

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Employment Information

Employer:

Position:

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How did you hear about our school?

Please explain your interest and/or experience in massage therapy education:

I certify that the information given in this application is true and correct. Should any of the information I have given change, I will notify the school immediately.

Online Privacy Policy: The student information collected is: contact, educational and health. The student is not required to submit information online and may do so at the Institution via the handwritten forms. The student has some control over the release of information from their education records. A student must provide written consent before the Institution can disclose information to a third party. The school shall provide and permit access to student’s records as required for any accreditation process initiated by the institution, NACCAS or licensing body. Students have the right to inspect and review their education records and seek to amend their education records when there has been a legitimate error recorded. The student information is collected and stored securely as the Institution has met the appropriate internet security standards. Upon an update to this policy, a notification will be presented on our website. If this policy is not met, students may also file a complaint with the U.S. Department of Education at: 400 Maryland Avenue, SW Washington, D.C. 20202-5920.

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