SOM – Application For Admission

School Of Massage
Application for Admission

Date Today

First Name

Middle Name

Last Name

Name you prefer to be called

Date of Birth

Gender

Male Female

Country of Citizenship

Social Security Number

Email Address

Daytime Telephone Number

What is your current occupation?

Current marital status?

Type of Student

On Campus Commuter

Name of High School

High School Graduation

Address of High School

Please submit copy of High School Diploma

Name of College/University

Date of College/University Graduation

Address of College/University

Please submit copy of College/University Diploma

Why are you interested in becoming a massage therapist?

What are your career goals within the massage therapy field?

How do you think this program will help you achieve those goals?

Please list any additional expectations you have regarding your enrollment and education in the Black Hills School of Massage.

Any physical limitations or health conditions that may impact your ability to perform massage therapy?

Any previous injuries, surgeries, or chronic illness relevant to massage practice?

For practicing medical professionals, you might be required to have a TB test, see your health care provider for administration of this test prior to the beginning of the school term.

Do you have any previous understanding of human anatomy and physiology?

Do you have any knowledge of different massage modalities (Swedish, deep tissue, sports massage)

Please explain any awareness of ethical (boundaries, scope of practice, cross gender massage, confidentiality, etc.) considerations in massage therapy

Do you have any experience with customer service or client interaction?

Do you have commitment to maintaining professional boundaries?

First Name

Last Name

Street Address

City/State

Postal Code

Telephone

Relationship

School Of Massage Application for Admission

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School Of Massage
Application for Admission