Maui Massage Therapy School - Maui Academy of the Healing Arts

Applications

Information and Policies

Financial Aid

International Students



• Click here for a printable version of this application • Click here for International Student application

Personal Information:

Name:
	First Name	MI	Last Name

Address:
	Street Address or PO Box


	City	State	Zip

Phone:
	Daytime	Evening

Email:		Social Security #:

Sex	Male Female	Date of Birth:

Current Employer:

Name:

Address:
	Street Address or PO Box


	City	State	Zip

Phone:
	Daytime	Evening

Emergency Contact:

Name:

Phone:
	Daytime	Evening

Entrance Requirements High school diploma or equivalent Minimum age of 18, or written permission from parent or legal guardian No diseases or disabilities that would jeopardize the health and safety of the student or client in fulfilling the training or duties of a massage therapist. Personal interview with the Administrator $78.00 non-refundable application fee - Make check payable to San Corp. Completed Health Evaluation
1) Briefly summmarize your education, both formal and informal. List any degrees attained.

2) Summarize previous massage training, experience, professional massages recieved, short trainings, workshops, schools and instructions with dates of each.

3) Why do you want to become a massage therapist?

4) How do you best learn?

5) Do you have any specific learning difficulties:

verbally (concepts and ideas):		visually (sight):

auditorally (hearing):		kinesthetically (touching or being touched):

6) Have you ever been convicted of a felony?		Yes	No

Health Evaluation

This questionnaire will remain strictly confidential and for the sole use of the administrative staff of the Maui Academy of the Healing Arts. The information you provide will help us assess your needs and consult with you appropriately. we are aware that our program is physically, emotionally, and academically demanding and it is important to us tha we contribute all we can to your success. Please completet each of the following.

1) List any medications taken regularly.


2) Do you have any physical limitations? Yes No
If yes, please describe:

3) Have you ever been treated for emotional disorders? Yes No
If yes, please describe:

4) Are you presently receiving treatment for any reason? Yes No
If yes, please list:

5) Do you have any allergies? Yes No
If yes, please list:

6) Have you had any injuries due to accident or sports? Yes No
If yes, please list:

7) Your primary care health provider:
Name
Phone

Do you have a present or past history of any of the following conditions? If so, please check.
Alcoholism		Leukemia
Back Problems		Polio
Convulsions/Seizures		Asthma
Ear Trouble/Hearing Loss		Colitis
Hay Fever (recurrent)		Sleep Problems
Hepatitis/Jaundice		Fainting/Blackouts
Kidney Disease/Trouble		Skin Trouble
Mononucleosis (infectious)		AIDS
Sinus trouble		Tuberculosis
Joint Disease/Injury		Mumps
Eye Disease		Rubella
Scarlet Fever		Head Injury
Intestinal/Stomach Problems		Pneumonia
Anxiety		Cancer
Chronic Pain		Diabetes
Depression		Varicose Veins
Eating Disorder		Drug Abuse
Rheumatic Fever		Heart Disease
Measles (red)

Other illness, surgery or injury:


Your signature below indicates that the information on this form is complete and true to the best of your knowledge. Falsification or omission of any pertinent information on this form or the Application form may be grounds for termination.

Name Date