Welcome To Teach Massage

Massage Therapy Programs
Online Application for Admission

PERSONAL DATA:

First Name *
Last Name *
Address 1 *
Address 2
City *
State *
Zip Code *
Email Address *
Home Phone *
Work Phone *
Birth Date (MM/DD/YY) *
Social Security Number *
Citizenship *

PROGRAM:

Select the program you are applying for from the list below.

Click here to select this course

Location: Dagsboro, DE
Start	End
3/13/06	9/6/06

Course: 600 Hr Massage Therapy
Format	Day Of Wk.
AM	MTWTF

Tuition: $6,350.00
Start	End
9:15am	2:30pm

Click here to select this course

Location: Dagsboro, DE
Start	End
4/17/06	11/9/06

Course: 600 Hr Massage Therapy
Format	Day Of Wk.
PM	MTWT

Tuition: $6,350.00
Start	End
5:15pm	10:30pm

Click here to select this course

Location: Dagsboro, DE
Start	End
10/13/06	10/7/07

Course: 600 Hr Massage Therapy
Format	Day Of Wk.
PM	Fri

Tuition: $6,350.00
Start	End
5:15pm	10:30pm

EDUCATION:

List educational institutions attended with the most recent first. Official transcripts MUST be submitted before a Certificate will be granted.

School Name 1
City / State
Dates From / To
Degree Earned
School Name 2
City / State
Dates From / To
Degree Earned
Degree Earned

EMPLOYMENT:

List current or most recent employment.

Employer
Address
City / State
Phone
Job Descrption
Dates Employed
Dates Employed

HEALTH RECORD:

Have you had any contagious diseases in the past 2 years?	YES��NO
If yes, please explain:
Do you have any health related issues the school should be aware of?	YES��NO
If yes, please explain:

REFERENCES:

Reference #1

Name
Address
City
State
Zip Code
Phone
Relationship
Relationship

Reference #2

Name
Address
City
State
Zip Code
Phone
Relationship
Relationship

OTHER:

Have you ever been convicted of a felony?	YES��NO
If yes, please explain:

CERTIFICATION:

Type your full name in the space below to indicate that you believe the information provided above is true and complete.
Full Name *

PAYMENT:

Provide your charge card information for the $75.00 registration fee. The $75.00 registration fee is refundable prior to the first day of class.

Note: The registration fee for Florida is $50.00 and is non-refundable.

Name On Card *
Card Type *
Card Number *
Experation Date *

PROCESS APPLICATION:

If you want a copy of this page for your records,
print it now before you submit the page.

Click on the Submit button just once. Depending on Internet traffic and server load it may take up to one minute for the order to be processed. However, if nothing seems to be happening, feel free to click again. You will not be billed twice.