Massage Therapy Certificate Program Application for Admission

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1 Massage Therapy Certificate Program Application for Admission Thank you for your interest in the Massage Therapy Certificate Program at. To be considered for the program, prospective students must complete all portions of this application. Please read carefully! Incomplete applications will not be considered, and your place in the program will not be assured until all application portions are complete. Application Process 1. Complete the Application/Enrollment Processes (available online at 2. Complete the Massage Therapy Certificate Program Application and submit all required elements (available online at 3. Complete EMC 425 or equivalent or submit a current, valid Healthcare Provider CPR card APPLICATIONS WILL NOT BE CONSIDERED UNLESS ALL REQUIRED ELEMENTS ARE SUBMITTED. PLEASE SEND THE COMPLETED PACKET TO: Building 4, Cosmetology & Wellness San Bruno, CA The Massage Therapy Certificate Program offers one enrollment opportunity each year for the 500-hour, two semester program that starts in the Fall semester and completes in the Spring semester. SCHEDULE DAYS TIMES LOCATION COST Fall Semester Monday through Thursday 6:00 pm - 10:00 pm Approx $1,200 Spring Semester Monday through Thursday 6:00 pm - 10:00 pm Approx. $405 NOTE: A BACKGROUND CHECK AND PROOF OF FREEDOM FROM TUBERCULOSIS WILL BE REQUIRED AFTER ADMISSION INTO THE PROGRAM. APPLICANTS WILL NOT BE CLEARED FOR ENROLLMENT WITHOUT THESE ELEMENTS. Massage Therapy Certificate Program Admission Application Page 1 of 7 Updated 4/2015

2 Massage Therapy Certificate Program Application for Admission Applicant: Complete this form and return to the at the address listed above. Date Student G Number Name Male Female Address Number & Street City State Zip Code Home Phone Work Phone (please print legibly) Date of Birth Country of Citizenship A full statement of your academic record is required for admission to the Massage Therapy Certificate Program. Please list below the names of your high school and all colleges and/or universities you have attended. Institution and Address From (Mo/Yr) To (Mo/Yr) Major/Area of Study Degree Received Have you ever been dismissed from any school or college? If so, explain. List full-time occupations to date: Massage Therapy Certificate Program Admission Application Page 2 of 7 Updated 4/2015

3 Do you have prior education in Massage Therapy? Yes No Name of School, Mentor, or Instructor Location Approximate Date of Training Number of Hours Do you have any health limitations that will affect your ability to perform the work required in this profession? Applicants should be able to stand for a period of several hours and be able to bear their body weight on their hands and forearms. Yes No If yes, please explain: How did you hear about the Massage Therapy Certificate Program? Explain: Why are you interested in learning Massage Therapy? Please attach a short essay (personal statement) responding to this question. Responses must be at least ½ page in length; may be no longer than 1 page in length, and should be typed if at all possible. Personal statement attached? Yes To be considered for admission, all students must complete the English and Math Placement Test within the past two years. The English or Math Placement Test MAY be waived for students who have completed an Associate, Baccalaureate, or higher degree and indicate so on this application. To make a placement test appointment, please go to I hereby certify that the information I have given in this application is complete and correct to the best of my knowledge. I understand that no action will be taken regarding my application until the Massage Therapy Certificate Program has received all documents. Student's Signature Date Return Application To: Building 4, Cosmetology & Wellness San Bruno, CA Massage Therapy Certificate Program Admission Application Page 3 of 7 Updated 4/2015

4 Emergency Contact Form Name Male Female Prefer not to specify Address Number & Street City State Zip Code Home Telephone: Work Telephone: In case of emergency, please notify Phone number Do you have any disabilities that may require additional assistance and support? Yes No If yes, please describe: Do you have any allergies or health problems? Yes No If yes, please list: Due to the strenuous nature of the Massage Therapy Certificate Program, we would suggest a complete physical examination prior to enrolling. Regardless of whether or not a physical examination is received, A CURRENT TB TEST RESULT IS REQUIRED. THE TEST MUST HAVE BEEN ADMINISTERED WITHIN THE LAST SIX (6) MONTHS. A NEGATIVE TEST RESULT WILL BE ACCEPTED. IF THE RESULT IS POSITIVE, A NOTE FROM A PHYSICIAN (MD) IS REQUIRED, VERIFYING THAT THE STUDENT IS HEALTHY AND CAPABLE OF PARTICIPATING IN THE PROGRAM. Massage Therapy Certificate Program Admission Application Page 4 of 7 Updated 5/2015

5 Massage Therapy Certificate Program Application Checklist Please use this checklist to ensure that you have completed all required application elements and included them with your application. Include this checklist with your submitted application packet. Name of Applicant Address: 1. Copy of Placement Test Results: Math and English (or documentation of degree) 2. Completed Massage Therapy Certificate Application, Signed and Dated (pages 2 and 3), including personal statement regarding reasons for wanting to learn about Massage Therapy 3. Signed and Dated Contract (bottom portion of page 5). You will receive your contract at orientation. 4. Completed Skyline Emergency Contact Form, Signed and Dated (page 6) 5. Proof of Freedom from Tuberculosis (negative test result from within the last 6 months or, if result was positive, a physician s (MD s) statement certifying health) 6. Transcript of completion of EMC 425 or equivalent or copy of your valid Healthcare Provider CPR card. Unofficial transcripts may be printed through WebSMART and submitted for coursework completed through the San Mateo Community College District. 7. Documentation/receipt from the within the last 12 months showing proof of having received a Professional Massage. 8. Completed Application Checklist 9. Application Packet submitted by deadline (unless expressly permitted to submit after deadline) Application Packet must be submitted through the mail or delivered in person to: Building 8, Business Division Office San Bruno, CA 9406 Accepted and/or waitlisted applicants will be notified via . IMPORTANT NOTE: Program classes begin on the first weekday of the Fall semester in Building 4, Room ***Once a student is accepted, s/he must bring money orders/cashier s checks as instructed to the first night of class or enrollment will be forfeit.*** Massage Therapy Certificate Program Admission Application Page 5 of 7 Updated 4/2015

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