2025 Massage Therapy Enrollment Form

2025 Massage Therapy Enrollment Form

If you were enrolled in 2024, you do not have to fill out this form. Staff will contact you to re-enroll.
Are you a registered client of the MS Center?*

YesNo
To become a client, contact Judi@centers4ms.org. Only registered clients are eligble to apply for the Massage Therapy Program.
NAME*
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number (home)*
Please enter a valid phone number.
Phone Number (cell)
Please enter a valid phone number.
EMAIL*
example@example.com
Mobility
Do you use any assistive devices?

YesNo
Which assistive devices?*
You can choose more than one by holding down the CTRL button and clicking
Do you require assistance to transfer?

YesNoComments
Medical Contacts
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Primary Physician Contact Name*

First NameLast Name
Primary Physician Phone Number*
Please enter a valid phone number.
Neurologist Contact Name*

First NameLast Name
Neurologist Phone Number*
Please enter a valid phone number.
Date of submission

MonthDayYear
Should be Empty:

Mobility