Please complete each section of this application. Any falsification is grounds for rejection or for cancellation of enrollment agreement. This information is strictly confidential. Personal Data Last Name First Name Middle Maiden Name Phone SSN. Date of Birth ID#/DRV Lic. # Email Address Apt # City State Zip Code Permanent Address: (if different) City State Zip Code Telephone Race or Ethnic origin Marital Status Spouse's Name U.S. Citizen? Yes No Alien Registration No. Name as you want it to appear on your Certificate Nearest Relative (Excluding spouse, or other relative living with you) Relative's Name Relationship Address Day Phone Evening Phone Emergency Contact Emergency Contact Name Relationship Emergency Contact Address City State Zip Day Phone Evening Phone How did you hear about Soothing Arts? (check all that apply) Internet Signs Yellow Pages Radio Flyer Friend Event OtherCurrent EmploymentAre you currently employed? Yes No Employer Phone No. Supervisor Address City State Zip Position How Long Education and TrainingGeneral Requirements: Florida LAW requires that all students and licensee applicants for a massage therapy license must have a high school diploma or equivalency. Please provide transcript, diploma or GED Certificate. High School City & State/Country Year of Graduation College City & State/Country Major/Year of Graduation Other Training City & State/Country Year/Date of Completition References(Please fill in all information, and use references you have known for at least three years) Name Mailing Address & No. Street City, State, Zip Phone Name Mailing Address & No. Street City, State, Zip Phone Name Mailing Address & No. Street City, State, Zip Phone Name Mailing Address & No. Street City, State, Zip Phone OtherProgram of Interest Massage Therapy Skin Care Clinical Skin Care Nail Specialist Do you have previous experience in the health care or beauty industry? Yes No If yes, please explain Other than traffic violations, have you ever been convicted of a crime? Yes No If yes, please explain Will you need financial assistance through a payment plan? Yes No What hours can you attend classes? When can you begin your training? Do you have any physical health problems that may interfere with your ability to participate in class? "Yes" "No" If yes, please explain If you are applying for the massage therapy program, do you have any physical health problems that may interfere with your ability to give or receive massages? Yes No If yes, please explain Below or on a separate sheet of paper, explain your personal and professional goals and how they relate to your chosen field of study. Why are you choosing to attend this program? Special AccommodationsStudents with special needs due to disability should advise the school prior to enrollment to assure that reasonableaccommodations can be made to facilitate training. Please describe your needs:Soothing Arts Healing Therapies School of Massage reserves the right to deny admission to any applicant who does not demonstrate the ability to benefit from the training program, or who does not demonstrate the ethical standards required of the profession for which the training is offered. Full Name By checking, I certify that the information provided herein is true and accurate to the best of my knowledge. I also state that I have read and agree to abide by the policies stated in the School catalog. If accepted, I agree to uphold the ethical standards required of the profession for which I am being trained.