Phoenix Awakening Massage – Online Enrollment Form

A New Beginning School of Massage MS1058
Phoenix Awakening Massage

Online Enrollment Form
Please fill in all of the fields below in order to complete your online enrollment form:

Name:

Home phone:

Cell phone:

Address (Line 1):

Address (Line 2):

City:

State:

Zip Code:

Why are you interested in attending Massage Therapy school [up to 400 char.]?

Where did you hear about us?

Planning to attend:

When do you want to start classes?

Can you commit to a 6-month program?

Do you need financial assistance?

In Case of Emergency:

Name of nearest relative:

Name of spouse:

Academic History:

Name of high school:

Did you graduate?

If yes, diploma or GED*?

* A high school diploma or GED is not required to attend our programs.

Did you attend college?

Did you graduate from college?

Work History:

Most recent employer:

Job title:

Are you still employed?

If no, why did you leave?

Military History:

Branch:

Rank:

Years of service:

Skills and duties:

Personal Information:

Do you have any criminal convictions?

If yes, please explain:

A prospective student is ineligible for state registration if he or she has been: a. convicted of or entered a plea of nolo contendere, was found guilty to or received deferred adjudication to crimes or offenses involving prostitution or sexual offenses. b. convicted of a violation of the Act within the past five years.

Do you have any history of dyslexia, learning disabilities, academic problems, or language barriers that may hamper your learning experience at the school?

Learning concerns?

If yes, please explain in detail:

Please enter your email address here,

Email address:

Re-enter email address:

The date/time of your online registration is:

By submitting this form, I certify that I am the person portrayed in the above fields on this enrollment form. Further, I agree to being contacted by Phoenix Awakening Massage electronically.