Massage Therapy Certification

Massage Therapy Certification Program Application | Denver Massage Therapy School

Massage Therapy Certification Program to our Denver Massage Therapy School:
What is your highest level of education? *
High SchoolVocational DegreeAssociates DegreeBachelors DegreeMasters DegreeDoctoral DegreePost-Doctoral DegreeProfessional Certification

Please enter your employment status *
Full TimePart TimeSelf EmployedStudentHomemakerRetiredDisabledUnemployed

Current Occupation *

Term Desired (dates are approximate). Each selection is a 600 - 675 Hour COMPREHENSIVE MASSAGE THERAPY CERTIFICATION PROGRAM. *
2017 Spring Intensive Certification Program: 1-27-17 through 6-17-172017 Fall Intensive Certification Program: 7-28-17 through 12-16-17

How did you hear about The Berkana Institute of Massage Therapy? *

Name of Emergency Contact *

Phone Number of Emergency Contact *

What is your relationship to this person? *

Do you smoke? The Berkana Institute of Massage Therapy is a holistic health oriented program. The campus and surrounding property are strickly non-smoking areas. Regardless of smoking history, all accepted students are required to sign a non-smoking agreement prior to enrollment acknowleging that they will not smoke in or around the campus property, and if they bring the smell of smoke into the Institute they will be asked to leave the campus. *
YesNo

Please list two references other than relatives. *
Name

Phone Number

Please describe any previous experience or training you have had in Massage Therapy as a provider or student. *

Have you ever been convicted of a felony? *
YesNo

If yes, please describe here:

Have you had any communicable diseases within the last two years? *
YesNo

If yes, please describe here:

Are you currently taking medications? *
YesNo

If yes, please list here and tell us what they are for:

Is there anything that would be helpful for us to know about your mental or physical condition while you are in school? *

Do you understand that this is an intense, high level incredibly challenging program which will require you to study extensively while in attendance and while away from the Institute? *

Please acknowledge here with your initials that you understand the following class times: 1. The Intensive Day Programs run Monday through Friday from 8:30am to 3:00pm. In the second, third and fourth quarter of the program, students must come to school one evening per week for Clinical Practicum. The Institute will attempt to accommodate your work schedule if you are employed. *

Please attach a photograph here. This can be a simple head shot of you. *

Please briefly describe 3 professional massage therapy experiences you have had. *