College of Massage Therapy 1600 Highalnd Drive, Blackfoot, ID 83221 208-785-3823

Please complete each section of this application. Any falsification is grounds for rejection or for cancellation of enrollment agreement. This information is strictly confidential.

PLEASE ATTACH A COPY OF YOUR DRIVER'S LICENSE OR PHOTO I.D.

U.S. Citizen? YesNoAlien Registration No.

Nearest Relative (Excluding spouse, or other relative living with you) Relative's Name Relationship Day Phone ( Evening Phone

Other Relative (Excluding spouse, or other relative living with you) Relative's Name Relationship ) Day Phone ( Evening Phone

Emergency Contact Emergency Contact Name CityState

HOW DID YOU HEAR ABOUT the College of Massage Therapy? (check all that apply) Other (Please RadioFlyer Yellow PagesNewspaper Signs specify)

Are you currently employed? Employer Address

(Mailing Address) (No. Street)

(Mailing Address) (No. Street)

(Mailing Address) (No. Street)

Have you ever pled guilty or been convicted of a crime as an adult or juvenile? (Check Yes even if the conviction was sealed or the judgment withheld No Yes Please explain:

Do you have criminal charges or warrants pending against you, or are you on probation or parole in this state or any other state?

PLEASE BE ADVISED THAT A CRIMINAL BACKGROUND CHECK IS REQUIRED FOR ADMISSION TO

THE COLLEGE OF MASSAGE THERAPY. A negative finding may result in admission to the College being denied.

Have you ever received a professional massage before? No Yes

Will you need financial assistance through a payment plan?

Do you have any physical health problems that may interfere with your ability to give or receive massages? (yes)(no If yes, please explain.

Do you currently have or have you had during the last two years a communicable disease If yes, please explain

Are you currently on any medications?

(no If yes, please list medications and condition being treated.

The College of Massage Therapy reserves the right to deny admission to any applicant who does not demonstrate the ability to benefit from the training program. As a condition of enrollment in any program at the College of Massage, the applicant must be able to give and receive a massage, and it is recommended that the applicant receive at least one massage prior to enrollment.

Students who are accepted for enrollment will be required to undergo and pass a tuberculosis test, as required by the hospital, in order to participate in the required internship training component of the program. If student elects to decline the TB skin test, the student must have a chest x-ray at their own expense. The estimated cost to be $125.00. Additionally, students must agree to provide proof of the following within the first 30 days.; records of immunizations for MMR (Measles, Mumps, Rubella), History of Varicella Disease (Chicken Pox), Titer, or proof of immunization, Tetanus Immunization (Tdap or TD) in the past 10 years. Students who do not pass either the skin test or x-ray for tuberculosis will be withdrawn from the program and may owe money to the school based on the refund policy.

I certify that the information provided herein is true and accurate to the best of my knowledge. If accepted, I agree to uphold the ethical standards required of the profession for which I am being trained.

Name (Please print) Signature:

The College of Massage Therapy does not discriminate on the basis o f Race, Color, National Origin, Sex, Handicap or Age in employment, or admissions to any of its educational programs or activities. As a condition of enrollment, in any program at the College of Massage Therapy, students must be able to give and receive a massage. The College of Massage Therapy reserves the right to contact any or all of the individuals listed on this Application.

PLEASE INCLUDE THE FOLLOWING WITH THIS APPLICATION:

$ 75.00 Application Fee Copy of High School Transcripts Diploma Copy of Driver's License