Please note: A $50 registration fee is due at the time of enrollment. Massage Therapy Training Program Application Form Applying For-- select one --January Day ClassJanuary Online/WeekendApril Night ClassSeptember Day ClassSeptember Night Class Contact InfoName* First Last Nickname Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Work PhoneCell Phone*Email Address* Gender* Female Male Date of Birth* Month Day Year Previous EducationHigh school: High School Name* City/State* Year Completed* Degree/Certificate*-- select one --DegreeGEDI can provide a copy of my diploma or GED*-- select one --yesnono, but I can provide a transcriptCollege / Vocational school: College / Vocational School Name City/State Year Completed Degree/Certificate Additional college / vocational school(s):If you attended more than one college or vocational school, enter information for additional school(s) here. US Citizen or Permanent Resident of USUS Citizen/Permanent US Resident?* No Yes If no, please complete the following: Country of Citizenship: Type of Visa: Visa Issued By: Ethnic BackgroundEthnic Background (optional)-- select one --African AmericanAsian/Pacific IslanderCaucasianHispanic/LatinoNative American/Alaskan NativeMulti RacialOther Have You Ever Been Convicted of a Felony?Have you ever been convicted of a felony?* No Yes If yes, please describe: Place of LivingPlace of Living*-- select one --RuralSuburbanCity EmploymentOccupation:* 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/hours: Personal/Business ReferencesTwo references are requiredFirst reference: Reference Name* Phone* Relationship to You* Second reference: Reference Name* Phone* Relationship to You* Emergency ContactsTwo emergency contacts are requiredFirst contact: Contact Name* Address* Phone* Relationship to You* Second contact: Contact Name* Address* Phone* Relationship to You* Health InformationDo 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 StatusFamily Status*-- select one --MarriedDivorcedWidowedSeperatedLiving with Signifigent OtherSingleIf you have children, please give ages: Massage BackgroundHave you received a professional massage before?* No Yes Students are required to receive two professional massages, one from a female therapist and one from a male therapist, before class begins. If yes, what kinds and how often? Have you had any previous training in massage?* No Yes If yes, please describe: How did you hear about LHAA?How did you hear about LHAA?*-- select one --LHAA WebsiteNatural HealersFamily/FriendPhone BookWord of MouthEventAdvertisementOther EssayEssay*Please write an essay to include the following 3 subjects: Why you would like to attend LHAA? What you consider your strengths and challenges? Your professional goals? (150-250 words) A $50 registration fee will be due before the first day of class.
