Application

Application
Link to our website: MIDWESTINSTITUTE.EDU
Tell Us About Your Goals
Name

First NameLast Name
Preferred Name/Nickname?
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Referred by:
Which program are you considering?
Which schedule works best for you?
*All Massage Therapy students must submit a Background Check Authorization form and pay the $20.00 background check fee during the enrollment process to determine enrollment eligibility.
How soon are you hoping to start?
Have you ever been convicted of a Felony?
What is the best contact method and time to reach you?
How did you get interested in this field?
What matters most to you in choosing a school?

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Readiness & Support System
What is motivating you to go to school?
What challenges might make attending classes difficult?

Other
What type of support do you have at home?
Do you have children?
If yes, age(s)?
Education Background
Highest education completed
Name when attending:

First NameLast Name
High School Name
Completion Year
College Name
Degree Obtained
GED Testing Center
Date GED received
Work Experience
Are you currently working? If so, what hours?
Current employer
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your role/responsibilities
How long have you been there?
Final Questions
What strengths do you believe will help you be successful in your program?
Where do you hope to be one year from now?
Anything else you'd like us to know before your admissions appointment or any questions you would like addressed?
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Time

Hour Minutes

AM/PM Option
Please verify that you are human
gclid
AC:
Should be Empty:

Application

Tell Us About Your Goals

Your Readiness & Support System

Education Background

Work Experience

Final Questions