Arizona Massage Therapy School Application

Tucson Campus

Mesa Campus

Flagstaff Campus

Applicant Information:

Last Name

First Name

Middle Name

Telephone #

Mailing Address

City

State

Zip Code

Birth Date (mm/dd/yy)

Social Security #

Occupation

Email Address

Gender

Male

Female

Other

Age Group:

US Citizen:

Yes

Ethnicity:

Is English your native language?

Yes

Please specify your native language

How did you hear about this school?

In Case of Emergency, Please Contact:

References - Please list two people unrelated to you:

Name:

Address:

Telephone:

Name:

Address:

Telephone:

Education:

Name of High School or GED

Date Graduated (mm/dd/yy)

Street Address

City

State

Zip Code

Name Recorded on Transcripts ( If Different From Application)

Highest level of education Completed:

GED

High School

Some College

Undergraduate

Grad School

Name of College or University:

Year From (yyyy):

Year To (yyyy):

Degree or Certification:

Financial Aid:

ASIS is eligible to offer Federal Financial Aid for those who Qualify. For more information please click here.

Are you currently, or have you since the previous July, received Federal Financial Aid?

Yes

Do you have previous Experiences or Trainings in Massage Therapy?

Yes

Please list previous Experiences or Trainings in Massage Therapy: ( List names of schools and /or trainings and dates attended )

In order to protect the integrity of the massage therapy profession, the Arizona Massage Board performs background checks on persons seeking an Arizona massage therapy license. Not disclosing a criminal record may prevent you from becoming licensed. While ASIS is unable to guarantee prospective students licensing eligibility, prospective students are encouraged to contact the Admissions Department to discuss individual circumstances.

Have you ever been convicted of a felony?

Yes

Are there any things you would like us to know about your mental or physical health (ie. communicable diseases, surgeries, medications, allergies, physical limitations.)? This could be pertinent for receiving massage in the class environment.

Yes

How did you become interested in the field of massage therapy and what is your healthcare philosophy?

Attestation

I have completed this application to the best of my knowledge and I state that the information given here is true and correct.

Student Signature:

Date:

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Application Instructions:

Campus and Program of Interest: