| Applying For: | |
| First Name: | |
| Middle Name: | |
| Last Name: | |
| Address: |
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| City: | |
| State: | |
| Zip: | |
| Home Phone: | |
| Work Phone: | |
| Cell Phone: | |
| Email Address: | |
| Social Security Number: | |
| Gender: | Female Male |
| Date Of Birth: | (mm/dd/yyyy) |
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| US Citizen or Permanent Resident of US? | No Yes |
| If no, please complete: |
| Country of Citizenship: | |
| Type of Visa: | |
| Visa Issued By: | |
| Ethinic Background: | |
| Have you ever been convicted of a felony? | No Yes |
| If yes, please describe: | |
| |
| Place of Living: | |
| Occupation: | |
| Employer's Name: | |
| Employer's Phone: | |
| How Long at Current Job? | |
| Annual Salary: | |
| Do you plan to work during school? No Yes |
| If yes, please describe work and hours: | |
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| Do you have any medical, physical, or psychological conditions that may require special attention or adaptation to effectively complete the LHAA training program? | No Yes |
| If yes, please describe: | |
| Family Status: | |
| Children, If yes, please give ages: | |
| Have you received a professional massage before? | No Yes |
| If yes, what kinds and how often? | |
| Students are required to receive two professional massages, one from a female therapist and one from a male therapist, before class begins. |
| Have you had any previous training in massage? | No Yes |
| If yes, please describe: | |
| How did you hear about LHAA? | |
Please write an essay of 150-250 words about: - Why you would like to attend LHAA?
- What you consider your strengths and challenges?
- Your professional goals?
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| Payment Plan: | |
| A $50 Application Fee is required before enrollment. |
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