Massage Technician Application
SOUTH BAY MASSAGE COLLEGE Confidential Application for Admission
(Include a $75.00 registration fee with application) - High School or College Diplomas required & Government Issued Identification!
(Include a $75.00 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 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? 200 hours or 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.________(initials)
- I declare under penalty that the above information is true and correct.
_________________________________________________________________________________
Signature Date
