Holistic Center for Therapeutic Massage

Name:
Address:		City:		State	Zip
Telephone:	Home: Work: Alternate:
Email Address:	Date Of Birth: Age: Gender:
Emergency Contact:
High School:	Year Graduated:
College/Vocational:	Degree/Year Achieved:
Problems that may affect Massage Performance:	Please define any problems you may have that we may need to adress for additional ways of working massage therapy into your lifestyle.
Communicable Diseases:
Current Medications:
Mental Challenges:
Learning Challenges:
Have you ever been convicted of a crime?			If yes, explain here. (only felonies will effect the ability to become a massage therapist)
Why do you want to be a massage therapist?	Explain in detail.
What are your career goals?	Explain in detail.
What are your hobbies?	Explain in detail.
What are your strengths and how will they help you as a massage therapist?	Explain in detail.
Please outline your time management schedule to include school study time into your life schedule.	Explain in detail.
Please outline a financial plan that will help you meet your tuition obligations.	Explain in detail.