Academy of Holistic Health Arts

APPLICATION FOR ADMISSION

 

Holistic Massage Therapy

Holistic Health Practitioner
(choose one)

Holistic Massage Specialist

Holistic Massage Instructor
 

Holistic Massage Therapist

Other Classes or Workshops

 

Last Name: First Name: MI:

Street Address or P.O. Box:

City: State: Zip:

Alternate Address:

Soc. Sec. #: Date of Birth: Sex: M F

Birth Place:

Drivers License #: Car Lic. #: State:

Marital Status:

Housing: Own Home Live with Parents Rent / Lease

Number of Dependents:

Name

Relationship

Age

Have You Been Under The Care Of A Physician Within The Last 2 Years: Yes No

Reason:

 

List Any Medications You Are Taking:

Do You Have Any Allergies? Yes No If Yes, What?

List Any Problems, Feeling, Or Expectations That Might Delay Progress In Your Program Requirements For Licensing:

List Names And Phone Numbers Of Persons To Call In Case Of An Emergency:

Name Address City, Zip Phone #

Citizenship Status: U.S. Permanent Resident Other (Specify)

Alien Reg. #

Veteran: Yes No

 

Current Employers Name, Address & Phone Numbers:

Name Address City, Zip Phone #

 

How Did You Hear About Our Program?

Are You Interested In: Full Time Part Time A.M. P.M.

If Under 18, Please Provide Name And Phone Number Of Parent Or Guardians:

Name of Parent /Guardian Address City, Zip Phone#

Parent Or Guardian's Signature And Date For Approval Of Student's Under 18 On Course Of Study Has Selected:

__________________________________________________________________________________________________________

Parent Or Guardian's Signature And Date

 

Education Background:

Highest Degree Attained: High School College Associate

Please List High School, Colleges And Universities Attended, Location ( City & State ), And Major Field Of Study.

Name Of School Attended City & State Major

What Languages Do You Speak?

 

The Academy of Holistic Health Arts does not discriminate on the basis of age, sex, sexual orientation, religion, race, physical handicap, color, marital status, ancestry or national origin. We are pleased to accept all qualified students.

 

Thank you for taking the time to complete this application.

PLEASE NOTE:

Prior conviction of a felony or misdemeanor may preclude applicant from obtaining a city, county, or state license.

Contact your local City, County or State for details.

STUDENT TUITION RECOVERY FUND (STRF). If you are not a resident of California, you are not eligible for the protection under, and recovery from, the Student Tuition Recovery Fund

 

_______________________________________________________________________

Student's Signature and Date

Please Send Application and $350.00 for application fee to:

Academy of Holistic Health Arts

2357 S. San Jacinto Ave.

San Jacinto, Ca. 92583

Questions Call (951) 766 - 0227

 

ANY QUESTIONS OR PROBLEMS CONCERNING THIS SCHOOL THAT HAVE NOT BEEN SATISFACTORILY ANSWERED OR RESOLVED BY THE SCHOOL SHOULD BE DIRECTED TO:

THE COUNCIL FOR PRIVATE POST 

SECONDARY & VOCATIONAL EDUCATION

400 R STREET, SUITE 5000

SACRAMENTO, CA. 95414

(916) 445 - 3428