Maui Massage Therapy School - Maui Academy of the Healing Arts

Applications

Information and Policies

Financial Aid

International Students



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

Full Name:
Email Address:
Foreign Street Address:
City:
Country:
Code #:
USA Street Address:
City:
State:
Zip Code:
Local Phone:
Passport Number:
Sex:	Male Female
Date of Birth:
Age:
Local Emergency Contact:
Phone:
Street Address:
City:
State:
Zip Code:

Pre-requisites for enrollment
High school diploma or equivalent Minimum age of 18 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 $100 non-refundable application fee - Make check payable to MAHA. Completed Health Evaluation

Briefly summarize your education, both formal and informal. List any degrees obtained.


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


Write a brief paragraph about your personal and professional goals, relating how this program is relevant to you.


Do you have any specific learning difficulties:
Verbally (concepts and ideas)	Visually (sight)
Auditorally (hearing)	Kinesthetically (touching or being touched)

Do you have proficiency in English?
Speaking	Yes No
Understanding	Yes No
Written	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