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Institute of Natural Therapies Professional Massage Therapist

Program Application

Please submit by August 20; however, applications are accepted until classes begin.

Name_____________________________________________________________________________________

Last   /   First   /   Middle   (Preferred Name)

Address ___________________________________________________________________________________

Street   /   City   /   State   /   Zip

E-mail address______________________________________________________________________________

Home telephone________________________________  Emergency telephone___________________________

Work phone____________________________________ Social Security Number__________________________

Birth date: _________ /_______/_______             Married            Single            Other__________________________

Month            Day            Year

Employed by ________________________________________________________________             Unemployed                              (Name of business)

Are you currently a student elsewhere?_______ If yes, where:___________________ Are you disabled?_________

Have you ever filed for disability compensation?___________  Do you have a learning disability?_______________

Do you have any injuries that may prevent you from giving or receiving massage therapy? _____________________

If yes, describe ______________________________________________________________________________

Do you have any special circumstance that we need to know about to best assist your learning?________________

__________________________________________________________________________________________

Other workshops or related seminars_____________________________________________________________

High School or GED from ______________________________________________________________________

College ______________________________________   Degree Earned ________________________________

Licenses and certifications _____________________________________________________________________

Have you ever been convicted of a violation of the penal laws of any State or of the United States?        Yes              No

If yes, explain (use an additional sheet of paper if necessary) ___________________________________________

 __________________________________________________________________________________________

Were you referred to I.N.T. by an I.N.T. graduate? _______ If so, who and when? ____________________________

Check box if you now own a massage therapy table.                (You will receive a discount on your initial payment.)

I hereby certify all the above statements are true. I understand that falsification or failure to disclose information on this application or any attached materials will be considered fraud and can cause me to be dismissed immediately from this school without refund or diploma.

X______________________________________      _________________________________________________

                  Your Signature                                                                                          Date

X______________________________________      _________________________________________________

                  I.N.T. Administrator Signature                                                                Date

Sending your application and fee early will ensure your space in the class of your choice. All payments will be refunded by mail September 1 if your class option is cancelled. Please see page 14 for descriptions of options available and select below:

CHOOSE A LEVEL:

        Level I (100 Hours)              Level II (500 Hours)              Level III (806 or 906 Hours)

CHOOSE A CLASS LOCATION/SCHEDULE:

       Option 1 - Weekend Class in Houghton/Hancock

       Option 2 - Weekend Class in Marquette

       Option 3 - Weekend Class in St. Ignace (Northern Lower Michigan)

       Option 4 - Weekday Class in Hancock

If my option is cancelled, I can participate in another class option:              Yes              No

Please indicate your second choice_______________________________________________________________