APPLICATION FORM

NAME_______________________________________________ MAIDEN_______________

ADDRESS____________________________________________________________________

CITY_____________________________________ STATE____________ ZIP____________

SS#___________________ Date of Birth_____________ Marital Status _________ SEX____

HOME PHONE____________________________ CELL PHONE______________________

HIGH SCHOOL_______________________________________________________________

ADDRESS____________________________________________________________________

CITY____________________________________ STATE____________

YEAR GRADUATED__________________________________ GED___________________

COLLEGE___________________________________________________________________

CITY____________________________________ STATE____________

YEAR GRADUATED______________________ DEGREE____________________________

EMERGENCY CONTACT PERSON:____________________________________________

ADDRESS____________________________________________________________________

PHONE______________________________________ RELATIONSHIP_______________

How did you hear about NWAM?__________________________________________________
___ Friend ____ Flyers ____ Massage Therapist ____ Yellow Pages ____ News Media ___ Other
Have you ever had a massage? ___ Yes ___ No
Why do you want to be a Massage Therapist?_________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________



Massage Therapy Program
Application Deadlines

To apply for enrollment in any of the following class sessions, please submit this application by the appropriate date. This will allow sufficient time to schedule your Orientation Interview before your class starts. We recommend submitting your application as soon as possible to allow time for completion of all required enrollment paperwork. Please indicate the class session for which you are applying.

CURRENTLY FORMING MASSAGE THERAPY CLASS SESSION:
__EVENING Class every Tuesday & Thursday from 5:30 p.m. to 9:30 p.m. starting April 28, 2009.

APPLICATION DEADLINE: before March 1, 2009
(Classes could fill sooner than stated deadline.)
ORIENTATION INTERVIEW SCHEDULED: by March 15, 2009

APPLICATION DEADLINE: before September 1, 2009
(Classes could fill sooner than stated deadline.)
ORIENTATION INTERVIEW SCHEDULED: by September 15, 2009