Fall-Evening (August)
Spring-Day (January)
Last First Middle
Student ID#___________________________________________________________________________
Telephone (H)________________________ (C)________________________(W)___________________
Permanent Address_____________________________________________________________________
Street City State Zip
Mailing Address _____________________________________________________________________
Street City State Zip
Email _______________________________________________________________________________________
Health Care/Work/Educational Experience
What is your current occupation__________________________________________________________
Have you attended any other Therapeutic Massage Courses or Prerequisite Classes? ______Y ______N
If yes, Name and location________________________________________________________________
Description of Classes __________________________________________________________________
Do you hold a certificate from any other Health Education School or College? ______Y ______N
If yes, Name and location________________________________________________________________
Description of Classes __________________________________________________________________
(Please submit transcripts for review)
Catalog Year_________
(Semester pre-requisites were started)
Name Student ID # Date
List name and location of each college attended.
College City and State Date Attended
Check each level of education you have completed.
GED High School Diploma AA Degree Other ___________________
High School graduated__________________________________________________________________
Name City State
Future Plans
Do you intend to complete your AA Degree?
Yes No
Prerequisite and Required Course Work
1. Attend Orientation for the Therapeutic Massage Program.
2. Copy of transcripts from College attended other than Phoenix College.
3. All courses must reflect a grade of “C” or better.
4. All prerequisites must be completed prior to application to the Therapeutic Massage Program.
5. Upon acceptance into Therapeutic Massage Program you must submit proof of:
____TB skin test/chest x-ray
____Hep B
____Health Provider CPR certification
____Drug screening
I certify that:
1. All information provided by me is true, correct, and complete.
2. It is my responsibility to provide all requested information to complete my file.
Failure to provide all requested information may adversely affect my evaluation.
3. Admission into the program is conditional until I have successfully completed all requirements.
________________________________ _______________
Applicant Signature Date
Phoenix College, one of the Maricopa Community Colleges, does not discriminate on a basis of race, color, gender, national origin, religion, handicap or age in
application, admission, participation, access and treatment of persons in instructional or employment programs and activities.
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