Massage Student Application

Student Registration Form

Fill out the form carefully for registration
Student Name*

First NameMiddle NameLast Name
E-mail*
example@example.com
Mobile Number*
Phone Number
Work Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Social Security # :*
Please upload a picture of your drivers license.*

Cancelof
Emergency Contact:*
Emergency Contact Phone Number:*
Please enter a valid phone number.
U.S. Citizen?*
If not a U.S. Citizen, what is your country of citizenship?
U.S. Resident?*
Country of Birth:*
Basic Information
Gender*
Have you ever been arrested and/or convicted of a felony?*
Please explain: (If answer was no, please type N/A)*
Educational Information
Are you a High School graduate?*
Highest Level of Education:*

Diploma/ GEDTrade SchoolAssociates DegreeBachelor's DegreeSome College
Name of Institution where you received your diploma, GED, or high school equivelency.*
Do you have your CPR certificate from the American Heart Association?*

YesNo
Anti-Bullying Policy

Here at Copper Tree Retreat: School of Massage, we are committed to creating a safe and respectful learning environment for all students. We take bullying very seriously and have ZERO tolerance for any form of bullying, harassment, or discrimination. ALL students are required to read and sign out ANTI-BULLYING POLICY.
Definition of Bullying

Bullying is defined as any intentional and repetitive behavior that causes harm or distress to another person. This includes physical, verbal, or emotional abuse, as well as cyberbullying through the use of electronic devices.

Examples of Bullying

Examples of bullying include, but are not limited to:

• Physical violence, such as hitting, pushing, or kicking

• Verbal abuse, such as name-calling, insults, or threats

• Emotional abuse, such as exclusion, humiliation, or intimidation

• Cyberbullying, such as posting hurtful messages or images online, or sending abusive texts or emails

Reporting Bullying

If you experience or witness bullying, harassment, or discrimination, please report it to our designated staff members Caitlynn Nutt, Virginia Savoldi, Mary Ann Bryan, Jason or Hailey Davis. We take all reports seriously and will investigate each case thoroughly.

Consequences of Bullying

Any student found to be engaging in bullying behavior will be subject to disciplinary action, up to and including expulsion from the program without reimbursement, forgiveness of any financial agreements, or refund of tuition paid or balances remaining. We reserve the right to involve law enforcement if necessary.
Conclusion

We are committed to providing a safe and respectful learning environment for all students. We encourage all students to treat each other with kindness and respect, and to report any incidents of bullying or harassment. Together, we can create a positive and supportive learning community.

By signing this I agree to all Copper Tree Retreat School of Massage Anti-Bullying policy and understand the consequences for not abiding by its rules.
Signature: By signing this I agree to all Copper Tree Retreat: School of Massage Anti-Bullying policy and understand the consequences for not abiding by its rules. *

Clear
General Information
Is there any reason you should not be able to complete this course?*
Have you ever had a professional massage before?*
What did you like most about it? What did you dislike about it?*
Why are you interested in the field of massage?*
What are you hobbies and interests?*
Do you have any unique needs, learning disabilities, health concerns, etc. that would require adapting this program to meet those needs?
Is there anything you would like to share with us about yourself?
Would you prefer day or evening classes?*

Mon-Fri 9:00 am - 4:00 pmMon-Wed-Fri 5:30 pm - 8:30 pm & alternating Saturdays 10:00 am - 5:00 pm
Signature*

Clear
Please verify that you are human*
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Student Registration Form

Basic Information

Educational Information

Anti-Bullying Policy

General Information