Download Student Application Form

APPLICATION FOR ADMISSION

Massage Therapy Institute of Missouri
5 South Ninth Street Suite204
Columbia MO 65201
Phone (573)875-7905 FAX (573)449-4933
e-mail: mtim1@hotmail.com
website <www.mtim.org>

Please answer all questions completely. If you need more space, use a separate sheet of paper. For more information, please refer to our admissions policy sheet.

PERSONAL INFORMATION
Legal Name (first, middle, last) .................Date of Birth .................Sex ...............Height ..................Weight

Name you use other than legal name ....................Social Security # ....................Driver’s License State & Number

Current address........................ City .....................State .............Zip Code .......Home Phone # ......Work Phone #

Permanent address................... City .....................State ..............Zip Code .......Phone # .................Cell Phone #

Current E-mail address

Emergency contact’s name & address......... City ...........State ...........Zip Code ....Home Phone # ...Work Phone #

EDUCATION please enclose documentation for admission

High School circle last year completed 1 2 3 4 ......................................................Graduated? [ ] yes [ ] no
..................................................................................................................... .......GED [ ]yes [ ]no
Name of School ......................Address ..................City ..................State ....................Zip Code

College circle last year completed 1 2 3 4 Post graduate _____ hrs ........................Graduated? [ ] yes [ ] no
Name of School .................Address ..............City ..........State ........Zip Code ..............Degree(s)/Major

Other (including workshops and seminars—list all that apply) .........Length of Program_________ Course of Study___________
Name of Institution ................Address ...........City ...........State........ Zip Code ...............Certificate?

Are you a veteran? [ ]yes [ ]no If yes, which branch?_______________ Dates of service ______________________

Are you eligible for Vocational Rehabilitation?________ If yes, name of counselor and phone # _________________________

Have you ever cancelled enrollment in or been terminated from an educational or training program? [ ] yes [ ] no
If yes, please explain:

Have you ever been convicted of a felony crime? [ ]yes [ ]no ( may or may not disqualify you )
If yes, when: __________ please explain:

(Criminal background check will be required for State Licensure.)

LICENSURE & CERTIFICATION
Have you ever been licensed or certified in any helping profession? [ ] yes [ ] no If yes, by what organization?
Name of Organization................ Address ....................City ................State ...........Zip Code ...........Phone #
.

Has your license or certification ever been revoked, suspended, or denied renewal? [ ] yes [ ] no If yes, please explain:

HEALTH (this information is needed for liability purposes)

Do you have any condition(s) which may limit your ability to participate (including pregnancy)? If yes, please explain:

Are you currently under the care of a licensed health professional? [ ] yes [ ] no If yes, please give the details:

 

Health professional’s name .....................Address............... City................State ...............Zip Code .........Phone #

Do you smoke cigarettes?______If yes, how many a day? ______Are you ready to quit? {Smoking prohibited during class}
Do you get regular exercise? ______________ What kind? ______________________________
Is there anything we should be aware of concerning your physical, emotional, psychological health, or any learning disabilities?
[ ]yes [ ]no
Please explain:

MTIM reserves the right to require a physical examination upon request. (Medical history forms due upon admission.)

SUPPORTING DOCUMENTS & FEES

Work experience:

Please enclose with your application a brief resume of any experience (including volunteer work) or special aptitude pertaining to massage therapy.

You must also include a written statement about why you wish participate in our program.
All applicants are required to receive a massage from a licensed therapist within the last year and enclose the receipt with your application.

APPLICATION FEE:
An application fee of $50.00 and supporting documents requested must be included with your application.

I certify that I have read and understand MTIM's Student Information document. I agree, if accepted as a student, to abide by MTIM's academic, billing, and conduct policies.

Signature:____________________ Witness:________________________ Date:_________________________

Please check your preference for: [ ] Day classes (11am-2pm) OR [ ] Evening classes (6pm-9pm)
Please check your preference for [ ] January Cohort OR [ ] July Cohort
Space available only; MTIM cannot guarantee openings
Continuing Education? ______________________________________________________________________
Continuing Education is $15/ hour, any class on our schedule, space available.

 

Mail your completed application, application fee, and supporting documents to MTIM