Still Waters Massage Institute Enrollment Application

Still Waters Massage Institute Enrollment Agreement
Student's Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Still Waters Massage Institute agrees to provide the following training:
Course program: Massage Therapy Program
Enrolling For:
Time Slot:
Time Slot:
Program consists of 39 weeks X 17.72 hours per week = 691 total hours.

This training will cost:

Registration fee: ........................................................................................... $ 50.00

Tuition: ........................................................................................................ $ 15,000.00

Books: ......................................................................................................... $ 500.00

Supplies & materials: ................................................................................... $ 1,300.00

Other fees and charges: .............................................................................. $ 1,150.00

TOTAL COST FOR THIS COURSE: ................................................................. $ 18,800.00
Payment Plan Options

(upon approval of credit)
Would you like to apply for a payment plan?
Down Payment Amount
If not yet determined, please leave blank
"Other" Down Payment Amount:
Please fill in the requested down payment amount.
Employment History
Current or Most Recent Employer
Supervisor's Name
Supervisor's Phone:
Start Date
End Date
Health History
By Signing this agreement and release you agree to release Still Waters Massage Institute from any liability for any physical condition or injury caused, aggravated, or affected by your participation in the program(s) or any courses taken at the Institute. You may be required to provide a physician's certificate describing any physical condition you disclose on this application stating whether or not the condition would be affected by your participation in the course(s) of study. Answer the following questions by checking Yes or No as appropriate, under each question.
Do you have any physical or mental conditions, including but not limited to, injuries or disabilities that could affect or prevent you from performing any massage techniques?
Physical or Mental Conditions -- Please Explain
Do you have or have you ever been diagnosed with a lower back condition, injury or disorder?
Lower Back Conditions -- Please Explain
Do you now or have you ever been diagnosed as having any hand, arm or forearm condition or disorder?
Hand or Arm Conditions -- Please Explain
Are you taking any prescribed medication that will affect or impair your ability to participate in or complete the program(s)?
Medications -- Please Explain
Do you have a documented learning disability?
Learning Disability -- Please Explain
Physician's Information
Current Physician:
Physician's Address:
Street Address
Date of Last Examination:
Physician's Phone:
City, State Zip
City, ST Zip
Other Information
Have you ever been convicted of a felony or misdemeanor other than traffic violation?
If "Yes," Please Explain. If "No" please type "N/A"
Driver's License / ID Number:
Issue Date:
Why do you want to attend Still Waters Massage Institute, and what are your expectations?
What are your biggest motivations in life?
Agreement is Binding:

This agreement will be binding only when it has been fully completed, signed, and dated by the student and an authorized representative of the school prior to the time instruction begins.

Changes int the Agreement:

Any changes in the agreement will not be binding on either the student or the school unless such changes are acknowledged in writing by an authorized representative of the school and by the student or the student's parent or guardian if he/she is a minor.
Effective Date:

MonthDayYear
Please Confirm:
Please Type Full Name
Please type your full legal name to confirm.
Should be Empty:

Still Waters Massage Institute Enrollment Agreement

Still Waters Massage Institute agrees to provide the following training:

Employment History

Health History

Physician's Information

Other Information