Name

Address

Email

Home Phone Work Phone

How did you find out about our school?
Select One Google Yahoo Another website Referral service From a friend Advertisment Phone book Other

To which section are you applying?
Select one M,T,W evening (12 month) T,W,Th afternoon (12 month) M,T,W,Th morning (9 month)
Second choice of sections:
Select one M,T,W evening (12 month) T,W,Th afternoon (12 month) M,T,W,Th morning (9 month)

High School (Name, location, degree & completion date)

College (Name, location, degree & completion date)

Graduate Studies/Other (Name, location, degree & completion date)

Please provide three references. Include the reference's name, their daytime phone and the reference's relationship to you. At least one reference must be from a job you've held or a school you attended.

(Name, daytime phone, relationship)
(1)

(2)

(3)

Please answer the following questions:

1. Why do you wish to study massage therapy?

2. What are you occupational and personal goals in seeking this training?

3. What are your expectations for the period of time you will be in training?

4. What has been your personal experience with massage therapy/therapists?

5. What personal characteristics do you have that you think will help you complete this program and become a successful massage therapist?

6. What expectations do you have after you finish this training?

7. Would you need any special assistance or adaptation due to any mental or physical conditions in order for you to successfully complete the program?

8. Have you ever been charged or convicted of a felony, and if so, what were you charged with?

An application fee of $50 is due upon submission of your application.
You may make payment by either credit card or check.  To pay by credit card, please call us at 540-552-2177.  To pay by check, please mail your check to Blue Ridge School of Massage & Yoga, Suite 106, 2001 S. Main St., Blacksburg, VA 24060.

Applicant signature
(by typing your name below this signifies an electronic signature)

Signature date