Massage School Application

DTY & HEALING ARTS SCHOOL OF MASSAGE THERAPY

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Date of Birth *

Phone Number *

Do you have a High School diploma, GED, or Homeschool Documentation *

Yes No

List any other Technical, College, Training you have. Include Institution, dates, & degree/certificate *

Health: Have you had any major medical/physical conditions you have been treated for in the last three years that may affect your ability to physically perform massage/bodywork therapy? *

Criminal history: Have you been convicted of a felony within the past five years? If yes, please explain. *

What has inspired you to enter the healing arts field as a massage therapist? *

Tell us a little about yourself! *

Choose the payment option you would most likely be using if you enter the massage program: *

Payment in full DTY Payment Plan

I authorize my credit card to be charged for: *

$50 Non-refundable Application Fee $50 Non-refundable Application Fee & $500 Non-refundable Registration Fee to hold my spot upon acceptance of application. (Card will not be charged registration fee unless accepted into the program.)

CREDIT CARD # *

CODE ON BACK OF CARD *

EXPIRATION *

BILLING ZIPCODE *

Typing your name below indicates that all the information on this application is true and correct to the best of your knowledge. Falsifying information on this application will be considered cause for dismissal from this program without refund of any monies paid. *

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