Application for Admission to KCHA's Professional Training Program

Last name:

First name:

Middle Initial:

Present Address:

City, State, ZIP:

Permanent Address:

City, State, ZIP:

E-mail Address:

Confirm E-mail Address:

Day Phone (with area code):

Evening Phone (with area code):

Birth Date:

Gender
Female
Male

Occupation:

Employer:

Employer's Phone (with area code):

Emergency Contact (name and phone):

1. Previous Education beginning with high school, list academic degrees and other certificates (include dates of attenance, name of school, and location) :

2.This program requires physical participation and some strength. Do you have any limitations (physical, emotional, mental) that would prohibit you from 100% participation? If yes, please explain:

3. Have you ever been convicted of a felony?

Yes
No

If yes, please provide details:

4. Have you ever received a professional massage? How was that experience for you?

5. In a few paragraphs, please describe:

• What it is about massage that attracts you
• What qualifications you feel you possess to be a practitioner
• Your plans, if any, to practice professionally after graduation

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