Massage Therapy Certificate Program – Apply Online 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 SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe 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 application fee will be due before the first day of class.