KMI Student Application Form

Student Application

Fill the form completely for consideration. Mahalo.
Name: *

First Name Last Name
Birth Date

Month Day Year
Phone Number: *

Area Code Phone Number
E-mail Address:
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How were you referred to us? *

Walk-In Word of Mouth Newspaper Ad Facebook Website Instagram Other (please specify)
Others:
Upload Transcript, Certification, Copy of U.S. Government Issued Photo ID:
Previous Education, Skills & Training
Describe your skills: *
Training or Certifications:
Tell Us About You
What's Your Favorite Flower, Color & Candy Bar?
Do you have an extra 20-30 hours per week to devote to your studies?

Yes No
What days are you available to attend school?

Mondays 5p-9p Tuesdays 5p-9p Wednesdays 5p-9p Thursdays 5p-9p Saturdays 8am-5pm
The Massage Workshop & Professional Licensing Program is about 9-10 months long depending on the student's pace. Are you committed to finishing the program in that time frame?

Yes No
Please share why you would like to attend Kapolei Massage Institute?
References

Please list two (2) references:
Reference 1
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Years Known: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Reference 2
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Years Known: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Signature

Clear
Please verify that you are human *
Should be Empty: