Certified Massage Therapist Application

indicates required fields

Personal Information

First Name *

Middle Name

Last Name *

Street Address *

Address continued

City *

State *

Zip *

Home Phone #: *

( )

Work Phone #:

( )

Additional Phone #:

( )

Email: *

Current Occupation:

Date of Birth: *

Gender

Race:

Are you a US Citizen or Legal resident? YesNo

Requested in Compliance with the Veterans Administration

How did you hear about us?

Promotional Code (optional): *

Application for ASHA Certified Massage Therapist Program

Class Schedules: * Winter Day 01/09/12 (deadline 12/31/12)Winter Night* 02/06/12 (deadline 1/28/12)Spring Day 04/09/12 Summer Night* 06/04/12Summer Day 07/09/12Summer Weekend-Only 06/16/12 *Night Schedule includes one Saturday per month

Date indicates start date of program.

Please complete your application by making a non-refundable $50 application fee through PayPal. * I understand and agree.

If payment is made by someone other than applicant, enter the credit card holder’s complete name here.

Program Terms and Conditions By checking the box it confirms your agreement to the following terms and conditions. During the course of the ASHA Training Program, I understand that I will be expected to participate fully in all course work and activities, including giving and receiving massage. I realize that I am participating in personal and professional growth classes that are not necessarily psychotherapeutic in nature but are focused on my relationship with my client and my personal attitude toward touch, massage, emotions, and success. I understand that work done within the program may have psychological, physical, or emotional effects and, if so, it is my responsibility to limit my degree of participation and inform others of such aspects. I realize that in the conduct of the training program, ASHA takes every reasonable precaution for the safety of all participants. However, ASHA cannot be responsible for the problems, medical or otherwise, of any individual in the program. I have responded truthfully to all of the inquiries made of me on this application. * I understand and agree.