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 NicknameAddress* 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Work PhoneCell Phone*Email Address* Gender*FemaleMaleDate of Birth* MM DD YYYY 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 NameCity/StateYear CompletedDegree/CertificateAdditional 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?*NoYesIf 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?*NoYesIf 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?NoYesIf 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?*NoYesIf 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?*NoYesStudents 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?*NoYesIf 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.
