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Online Application

Name*
First Middle Last
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Occupation*

Are you a United States citizen?*
- Yes
- No
If no, are you authorized to learn in the U.S.?
- Yes
- No
Have you ever attended Massage Therapy school?*
- Yes
- No
If so, when?
Have you ever been convicted of a felony?*
- Yes
- No
If yes, please explain
Have you ever received professional bodywork?*
- Yes
- No
If yes, what types?
Do you have any conditions which may require special attention or affect your ability to give or receive Massage Therapy?*
- Yes
- No
If yes, please explain
How did you hear about our program?*

Education
High School
Address
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Did you graduate
- Yes
- No
Degree
College
Address
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Did you graduate
- Yes
- No
Degree
Other
Address
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Did you graduate
- Yes
- No
Degree

Tell Us About Yourself
"Please tell us what inspired you to want to become a massage therapist?

Application Fee Amount
Application Fee
$0.00
Disclaimer
- I understand that an application fee of $75 is due upon submission of this application.
Credit Card

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Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

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4400 Weston Pointe Dr. Suite 120, Zionsville, IN 46077

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