Online Application
Step 1: Complete enrollment application

Personal Information
First Name: MI: Last:
Social Security Number: Date of Birth: Gender: Male Female
Email: Citizenship status:
Optional
Racial or Ethnic Background:
(check all that apply)
African-American/Black
Latin/Hispanic
White/Caucasion
Asian-American/Asian Native		 If you were not born in the United States, how many years have you lived in the United States:

What is the primary lauguage spoken in your household?

 

Address
Current Address:
Current City: 		State: Zip:
Current Phone Number:
 
Permanent Address:
Permanent City: 		State: Zip:
Permanent Phone Number:

 

Emergency Contact
First name: MI: Last name:
Address: City: State:
Zip: Phone Number: Relation:

 

Educational History
Highest Grade Completed:
List your current school and all other secondary schools you have attended.
Name of School City, State Dates of Attendance Dates or Expected
Dates of Completion
Do you currently Hold a Professional license:
Yes No		 If yes, in what field:
Have you ever been dismissed, placed on probation or supspended from school? Yes No
If yes, please explain:

Please list any other schools to which you are applying:

 

Work Experience
List the past 2 full and part time jobs that you've had starting with your current or most recent one.
Type of work Employer Dates of
employment		 Hours per
week/year
Current employers phone number:

 

Activities and Interests
List any extracurricular, community, and recreational activites that you participate in now or in the past. Use the box at the bottom to supply any explainations or elaborate on your activities/interests.
Activity Year(s) of participation Hours per
week/year		 Positions Held Plan to continue?
Additional information:

 

Other Information
How did you hear about Central Pennsylvania School of Massage, Inc.:
Other:
If any members of your family have been associated with the Central PA School of Massage, list their names, relationship to you and connection with the school:
If you have consulted with any alumni, faculty members, or admissions staff members regarding admission to Central PA School of Massage please list who and when:

Have you ever had a professional massage: Yes No
If yes, when and where :
Do you have any physical or emotional condition which would prevent you from giving/receiving a massage or performing receiving any adjunct procedure, or walking to/from class?: Yes No
If yes, please explain:
Have you ever been convicted of a felony: Yes No
If yes, please explain:

 

Course Information
I am requesting admission to the following program:
Student Status: Full Time Part Time Weekend
Do you need a flexible schedule: Yes No
Enrollment date:
Every attempt will be made to place you in your preferred session. However, our classes normally fill, so applying early will improve your chances of attending your preferred session. If we cannot place you in your preferred session, you will be placed in your second or third choice.
Second choice:       Third Choice:


My preferred day for an interview:
My preferred time for an interview: Day   Afternoon   Evening
I will be accompanied by a (recommended): Parent   Spouse   Friend

 

Educational Goals
The area below is for you to describe your educational career goal. Although you are not required to complete this section, by doing so may help the application review team. If you choose to complete this section, indicate by a brief statement your educational and career goals, as well as any additional information you feel will assist us in reviewing your application.
I hereby certify that all the information on this application for admission is current. All supporting credentials become the property of Central PA School of Massage, Inc. and are not returnable. I understand that, if accepted, falsified statements in the application shall be grounds for immediate dismissal. I understand that I am responsible for having a current PPD Test (Tuberculosis Test) on record by the end of Module H. I also understand that all students attending Central PA School of Massage, Inc. must attend weekend classes as scheduled after completion of Massage I. Absenteeism of weekend class may result in suspension.

 

 

By clicking Continue, you agree to the terms above