APPLICATION : THE MASSAGE INSTITUTE OF MEMPHIS
This is a printable form.

Date___________________________________    Applying for:    Day class     Night class

Name:_______________________________________________________________________________________________

Address:_____________________________________________________________________________________________        _____________________________________________________________________________________________

Work phone:___________________________________     Home phone:_______________________________________

Female    Male     Marital status:_____________________ Social Sec No.:_________________________________

Age:_________________  Date of birth:________________ Place of birth:_______________________________________

In case of emergency contact:____________________________________________________________________________

Address:____________________________________________________ Phone:__________________________________

Current employment:__________________________________________________________________________________

Address:____________________________________________________________________________________________

Previous employment:_________________________________________________________________________________

Address:____________________________________________________________________________________________

Educational experience

School:______________Location__________________Dates______________Area of study_______________Degree_____

___________________________________________________________________________________________________ ___________________________________________________________________________________________________

___________________________________________________________________________________________________ ___________________________________________________________________________________________________

Previous experience in/study of other healing arts____________________________________________________________ ___________________________________________________________________________________________________

APPLICATION : THE MASSAGE INSTITUTE OF MEMPHIS (PAGE 2)

Previous experience in/study of massage:__________________________________________________________________

How did you hear about the school?_____________________________________________________________________ Have you ever been convicted of a crime, other than traffic offenses?      Yes      No If yes, please explain:_________________________________________________________________________________ How do you expect to use the training?___________________________________________________________________ Do you have any medical or psychological conditions that The Massage Institute should be aware of? If yes, please explain:________________________________________________________________________________ Hobbies, interests, skills:_____________________________________________________________________________ Are you applying for either of the following? VA Assistance  Vocational Rehabilitation   If no, what payment method will you be using? Check   Cash   Payment Plan   References: Please list the names and addresses of 2 references other than family. Name:____________________________________________________________________________________________ Address:__________________________________________________________________________________________ Home Phone_________________________ Work Phone:______________________Years Known:_________________ Name:____________________________________________________________________________________________ Address:__________________________________________________________________________________________ Home Phone_________________________ Work Phone:______________________Years Known:_________________ Please fill out this application completely, sign it and return it together with a $50.00 non-refundable application fee made payable to The Massage Institute of Memphis. Signature______________________________________________   Date:______________________________________

We reserve the right to refuse admission to anyone we believe will not uphold the high standards of professional massage therapy or who is unable to benefit from the program.

The Massage Institute of Memphis
3251 Poplar Ave., Suite 25
Memphis, Tennessee 38111
(901) 324-4411