Massage Technician Application
SOUTH BAY MASSAGE COLLEGE Confidential Application for Admission
(A $175 Registration Fee with Application) - High School or College Diplomas required & Government Issued Identification!
(A $175 Registration Fee with Application) - High School or College Diplomas required & Government Issued Identification!
| south_bay_massage_college_application.doc |
CLASS TITLE: _____________________________________ START DATE: _________
Name_____________________________________________________________
Last Name First Name
Home Address Street________________________________________________ City____________________________________State_______Zip___________
Phone ______________________________________________
Home/Cell 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). Highest Grade Completed _____________ Degree_________________ _________________________________________________________________________________
Which Program are you interested in? 125 hours or 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 $175.00 application fee is non-refundable.________(initials)
- I declare under penalty that the above information is true and correct.
__________________________________________ ____________
Signature Date