Student Admissions Application - Therapeutic Connections School of Massage

Applicant Name:*

First

Last

Date of Birth:*

Social Security Number:*

Address:*

Street Address City State / Province / Region Postal / Zip Code

Home Phone:

Area Code

Phone Number

Cell Phone:*

Area Code

Phone Number

Work Phone:

Area Code

Phone Number

Email Address:*

How did you hear about us?*

Race:*

Disability:*

Yes

(Please explain):

Ability to Benefit
- Must be a high school graduate (information below)
- Ability to lift 50 lbs (demonstrate set-up of massage table)
- Basic computer skills (email, CD materials, resume, etc.)
- Washing State Patrol Background Check

Highest Grade Completed

Name of High School:

Graduation Date:

GED:

Date GED Attained:

Post High School:

What type of training?:

Certification (2yrs):

What type of certification training?:

Associate Degree (Name of College or Training Institute):

Dates Attended:

Bachelors Degree (Name of College or Training Institute:

Bachelors Dates Attended:

Current Employer (Name):

Phone Current Employer:

Area Code

Phone Number

Interested in Day or Evening Classes:*

Interested in Fall, Winter, Spring or Summer Session start?*

Sign up for our newsletter and receive school information about Massage School Programs, Student Clinic and Community Massage events:

Yes

In Case of Emergency Contact (Name):*

Relationship:*

Phone Emergency Contact:*

I verify all information is accurate:*

YES

Date:*

Please write one or two paragraphs why you want to become a massage practitioner?:*

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