Student Application

Online Student Application

There is a $50 application fee to submit this application, payment information is gathered below. Your application will not be submitted nor reviewed until this fee is paid.

First Name

Last Name

Social Security Number:

Address

Home Phone

Work Phone

Date Of Birth

Current Age

US Resident?

Country Of Residency

Is English your first language?

Emergency Contact:

Name

Phone Number

_______________________

Educational Experience:

High School:

Name of High School attended.

How many years attended?

Did you graduate?

College:

What College or University did you attend?

How many years atttended?

Did you graduate? (Y/N?)

Did you receive degree? (Y/N?)

Vocational School:

What Vocational school did you attend?

How many years atttended?

Did you graduate? (Y/N?)

Did you receive degree? (Y/N?)

_______________________

Health Issues:

Do you have any physical or mental health issues that may affect your ability to participate in a massage/bodywork training program? (Y/N?)

If yes, please explain:

Please list any medications you are taking under the guidance of a physician:

Please list any special needs that you may have in the training program:

_______________________

Please state your interest in this field. What personal qualities make you a good candidate for attending NAMTI's programs?

Have you ever received a professional therapeutic treatment related to these studies? How did theses treatments effect your decision to attend NAMTI?

Describe how you are planning to use the knowledge, skills, and experience gained through your certification program(s) or course work at NAMTI.

List your primary learning goals and how you plan to accomplish them while at NAMTI?

_______________________

Program Of Interest:

This application is in reference to the following start-date and Campus: (choose one)

Campus:

Program:
Select all the apply

840-hour Massage Practitioner's Program
500-hour Advanced Asian Bodywork
200-hour Professional Refloxology Training
Transfer Student Application

Start Date:

_______________________

The above information will not be used in any way to discriminate or judge you as a person, nor will any of the disclosed information necessarily make you ineligible as a candidate to enroll and attend Northern Arizona Massage Therapy Institute. In connection with my application with the school, I understand that a consumer report which may contain public records information is being requested. All prospective students understand furthermore that completion of this application is necessary yet does not guarantee any acceptance and attendance of Northern Arizona Massage Therapy Institute.

_______________________

Signature:

Credit Card Information

Credit Card Number:

Credit Card Verification Number:


Visa, MasterCard, Diners Club and Discover Card Verification Numbers are a 3-digit number that is printed on the back of your card. It generally appears to the right of your card number.	American Express Card Verification Numbers are a 4-digit number printed on the front of the card. It generally appears to the right of your card number.

Expiration Date: