Holistic Horizons
Application for enrollment into HOLISTIC HORIZONS program.
Please fill out all questions completely. Incomplete forms will not be eligible for consideration.
Application Fee -- $47.00 (non-refundable)
NAME________________________________________________________________________________
LAST FIRST MIDDLE MAIDEN
CURRENT ADDRESS___________________________________________________________________
______________________________________________________________________________________
PREVIOUS ADDRESS___________________________________________________________________
______________________________________________________________________________________
SEX: Female Male MARITAL STATUS: Single Married Divorced
SOCIAL SECURITY NUMBER________-________-__________
BIRTHDATE______________________ AGE__________
CURRENT OCCUPATION_______________________________________YEARS THERE?__________
PREVIOUS OCCUPATION_______________________________________YEARS THERE?_________
HOME PHONE__________________________ WORK PHONE_______________________________
CELL PHONE:___________________________ E-MAIL:___________________________________
HIGH SCHOOL GRADUATE? Yes No GED GPA________________
WHERE?_____________________________________________________________________________
LAST LEVEL OF EDUCATION COMPLETED:
High School : 10 11 12 College: 1 2 3 4 Graduate School
OTHER_______________________________________________________________________________
WHERE?______________________________________________________________________________
(Must have official transcript sent directly to HOLISTIC HORIZONS.)
HOW DID YOU HEAR ABOUT US?_______________________________________________________
___________________________________________________________________________________
LIST ANY PHYSICAL OR MENTAL DISABILITIES HOLISTIC HORIZONS SHOULD BE AWARE
OF:___________________________________________________________________________________
(ABMP requires that each applicant must have a physical.)
DO YOU FEEL THIS DISABILITY WILL INHIBIT YOUR ABILITY TO PERFORM THE DUTIES
REQUIRED OF A LICENSED MASSAGE THERAPIST? _____________________________________
DO YOU HAVE ANY PREVIOUS MASSAGE THERAPY EXPERIENCE?_______________________
WHEN?________________________ WHERE?__________________________________________
WHAT DOES THE WORD “HOLISTIC” MEAN TO YOU?_____________________________________
Write a 5 page essay explaining why you want to become a LMT & why you have chosen Holistic Horizons as your school choice. (typed)
MASSAGE THERAPISTS MUST SUBSCRIBE TO A HIGH STANDARD OF PERSONAL AND
PROFESSIONAL ETHICS AND STANDARDS! HAVE YOU EVER BEEN CONVICTED OR CHARGED WITH A CRIME? Yes No
IF YES, EXPLAIN______________________________________________________________________
______________________________________________________________________________________
HAVE YOU EVER BEEN EMPLOYED IN A JOB OR OCCUPATION WHICH WOULD CONFLICT
WITH THE PERSONAL IMAGE A MASSAGE THERAPIST MUST ADHERE TO? (Such as Strip
Bars, Novelty Establishments, Escort Services, Etc.) Yes No
IF YES, EXPLAIN______________________________________________________________________
BY SIGNING BELOW, I GIVE MY PERMISSION AND CONSENT FOR HOLISTIC HORIZONS TO
VERIFY ANY AND ALL INFORMATION INCLUDED ON THIS APPLICATION. I REALIZE THAT
THIS MAY INCLUDE A BACKGROUND CHECK, POLICE RECORDS, ETC. I ALSO REALIZE
THAT GIVING ANY FALSE INFORMATION WILL RESULT IN IMMEDIATE TERMINATION
FROM THE PROGRAM, SHOULD I BE ACCEPTED, AND THAT NO REFUNDS WILL BE GIVEN.
I ALSO AGREE THAT SHOULD I BE CHARGED OR CONVICTED OF A CRIME OR ENGAGE IN
UNETHICAL BEHAVIOR, I MAY BE TERMINATED FROM THE PROGRAM. I ALSO
UNDERSTAND THAT UNETHICAL, UNPROFESSIONAL, DISRUPTIVE, OR INAPPROPRIATE
BEHAVOIR, OR VIOLATION OF SCHOOL POLICIES AND PROCEDURES OR FAILURE TO
MAINTAIN A 70% GRADE OR HIGHER WILL RESULT IN TERMINATION FROM THE
PROGRAM, WITHOUT A REFUND.
_____________________________________________ ________________________________
SIGNED DATE
DEPOSIT RECEIVED__________________________ CHECK NO.______________________