Online Enrollment Form

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
ID#/DRV Lic. #
Email
Address
Apt #
Zip Code
Telephone
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

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 Other

Current Employment

Are you currently employed?
 Yes No

Address
City
State
Zip
Position
How Long

Education and Training

General 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.

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

Other

Program 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 Accommodations

Students 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.