| First Name |
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| Last Name |
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| Social Security Number: |
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| Address |
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| Home Phone |
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| Work Phone |
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| Email |
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| Date Of Birth |
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| Current Age |
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| US Resident? |
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| Country Of Residency |
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| Is English your first language? |
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| Emergency Contact: |
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| Name |
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| Phone Number |
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| _______________________ |
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| Educational Experience: |
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| High School: |
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| Name of High School attended. |
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| How many years attended? |
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| Did you graduate? |
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| College: |
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| What College or University did you attend? |
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| How many years atttended? |
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| Did you graduate? (Y/N?) |
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| Did you receive degree? (Y/N?) |
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| Vocational School: |
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| What Vocational school did you attend? |
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| How many years atttended? |
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| Did you graduate? (Y/N?) |
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| Did you receive degree? (Y/N?) |
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| _______________________ |
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| Health Issues: |
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| Do you have any physical or mental health issues that may affect your ability to participate in a massage/bodywork training program? (Y/N?) |
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| If yes, please explain: |
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| Please list any medications you are taking under the guidance of a physician: |
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| Please list any special needs that you may have in the training program: |
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| _______________________ |
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| Please state your interest in this field. What personal qualities make you a good candidate for attending NAMTI's programs? |
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| Have you ever received a professional therapeutic treatment related to these studies? How did theses treatments effect your decision to attend NAMTI? |
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| Describe how you are planning to use the knowledge, skills, and experience gained through your certification program(s) or course work at NAMTI. |
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| List your primary learning goals and how you plan to accomplish them while at NAMTI? |
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| _______________________ |
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| Program Of Interest: |
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| This application is in reference to the following start-date and Campus: (choose one) |
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| Campus: |
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Program:
Select all the apply
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840-hour Massage Practitioner's Program
500-hour Advanced Asian Bodywork
200-hour Professional Refloxology Training
Transfer Student Application |
Start Date: |
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| _______________________ |
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| 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. |
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| _______________________ |
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| Signature: |
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Credit Card Information |
| Credit Card Number: |
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| Credit Card Verification Number: |
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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: |
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Student Application
