| Name: First, Middle, & Last | |
| Maiden Name: | |
| S.I.N.: | |
| Home Address: (Street, Box, R.R.#) | |
| City/Town: | |
| Province/State: | |
| Postal/Zip Code: | |
| Resident Phone:(incl. area code) | |
| Business Phone:(incl. area code) | |
| Alternate Contact:(incl. area code) | |
| Email: | |
| Relationship: | |
| Date of Birth: (Day/Month/Year) |
| High School (Year) | |
| College (Year) | |
| University (Year) | |
| Other (Year) | |
| Degree/Diploma |
| 1.) Other occupation training (list all): | |
| 2.) Present Occupation: | |
| 3.) Other training in the health related/natural healing field (describe): | |
| 4.) Do you have any physical impairments(s), which could affect your performance as a massage therapist? Is so, explain: | |
| 5.) Do you have any previous massage experience (reading, workshops, research, etc)? | |
| 6.) Explain why you would like to become a Massage Therapist and why you would be an asset to the profession. What are your future plans? | |
| 7.) Why did you choose to attend the Alberta Institute of Massage? Please indicate how you heard about us or your source of referral: | |
| 8.) Are you prepared to move from your present location to practice massage therapy (to relocate for demand)? | |
| Have you ever been convicted of a criminal offence? If yes, please complete the following: | |
| City and Province: | |
| Date of Conviction: | |
| Nature of offence: | |
| Pardoned? | Yes No |
| Do you understand the fee schedule as set forth by the school (information on tuition and costs is specified on the "programs" section of this web site) and do you understand that the $150.00 administration fee is non-refundable? |