Philly Home Massage Collective
Membership Application
Personal Information
Name
*
First Name
Last Name
Email
*
example@example.com
Where do you live?
*
City
State / Province
Postal / Zip Code
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Massage License number
*
State(s) licensed in
*
Years of experience
*
Collective Information
Which county/counties do you service?
*
Chester County
Delaware County
Bucks County
Montgomery County
Philadelphia County
What modalities do you specialize in/have certifications in?
*
What would you like to improve about your current business?
*
What strengths would you like to contribute to the collective?
*
Would you be willing to participate in biweekly/monthly meetings? Most likely virtual.
*
Yes
No
By joining this collective, you would be committing to fostering an inclusive and respectful environment for all clients and fellow therapists, regardless of race, gender, sexual orientation, age, or ability. Inclusivity is a core value of the collective, and you would be required to agree to uphold these principles in all interactions. Do you agree with and commit to the inclusivity values outlined above?
*
Yes, I agree
If you have any questions or additional information that you would like to provide, please leave it here.
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