Application
SOUTH BAY MASSAGE COLLEGE Confidential Application for Admission
(Include a $75.00 registration fee with application)
(Include a $75.00 registration fee with application)
| south_bay_massage_college_application.doc |
CLASS TITLE: _________________________ START DATE: ________________
Name_________________________________________________________________________
Last Name First Name
Home Address _______________________________________________________________ Street City State Zip
Phone ______________________________________________
Home Work
E-mail Address ___________________________________
Birth Date _______________________ Gender (circle): Male or Female
Occupation___________________________________
Employment _________________________________________________________
Name of Company Street City State Zip
Education History (attach a copy of diploma if you have it) Highest Grade Completed ___________________ Degrees ____________________________
Which Program are you interested in? 175 hours, 300 hours, 500 hours, other _________
Health List any major existing physical conditions: ________________________________ Are you currently taking medications? _______________________________________________
In case of emergency, call _____________________________________________________
Name Relationship Phone
Course Information What are your goals in taking this course? __________________________
What prior experience (if any) do you have relating to massage? _________________________
Where did you hear about SBMC? (Circle) Beach Reporter Easy Reader Sign Net
Former student Friend Other _________________________
Declaration I understand that that $75.00 application fee is non-refundable.
- I declare under penalty that the above information is true and correct.
____________________________________________________________________
Signature Date
