Confidential Information. Applying for Day or Evening Class? * --Pick One-- Day Class Evening Class Contact Information First Name * Last Name * Address * Street Address Street Address 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zipcode * Home Phone * Enter Home Phone Number Here Cell Phone * Enter Cell Phone number here Work Number Enter Work Number here Email Address * Gender * Male Female Date of Birth * Previous Education High School * High School Name Here City * Enter High School City Here State * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Year Completed * Diploma or GED * ---Pick One-- Diploma GED Are you Able to provide a copy of diploma/GED? * --Pick One-- Yes No No, but I can provide Transcripts Upload Digital Copy of Diploma/GED/Transcripts Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 67.11MB (Optional) If you have a digital copy of Diploma, GED, or Transcripts you may upload them here. College/Vocational Education College/ Vocational School Name City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Year Completed Degree or Certificate Additonal College/Vocational School(s): If you attended more than one college or vocational school, enter information for additional school(s) here. US Citizen or Permanent Resident of the US US Citizen or Permanent Resident of US * Yes No If no, Then Country of Origin Type of Visa Visa Issued by Ethnic Background Ethnic Background (Optional) --Select One-- African American Asian/Pacific Islander Caucasian Hispanic/Latino Native American/ Alaskan Native Multi Racial Other Criminal Background Have you ever been convicted of a misdemeanor or felony other than for minor traffic violations (D.U.I. is not considered a minor traffic violation.) ? * Yes No If Yes, Please Describe here Describe the nature of the conviction(s) and provide the date(s) of the conviction(s). Place of Living Place of Living * --Select One-- Suburban Rural City Employment Occupation * Employer's Name Employer's Phone Number How Long at Current Job? Annual Salary Do you plan to work during School? Yes No If Yes, Please describe Work/Hours Personal/Business References Two references are required First Reference * Reference Full Name Reference Phone Number * Relationship to you * Second Reference * Reference Full Name Reference Phone Number * Relationship to you * Emergency Contacts Two emergency contacts are required First Contact * First Emergency Contact Full Name Contact Address * Contact Phone Number * Relationship to you? * Second Emergency Contact * Emergency Contact's Full Name Contact Address * Contact Phone Number * Relationship to you? * Family Status Family Status * --Select One-- Married Divorced Widowed Seperated Living with significant other Single If you have children, What are their ages? Massage Background Students are required to receive two professional massages, one from a female therapist and one from a male therapist, before class begins. Have you received professional massage before? * Yes No If Yes, What Modalities types) and how often? Have you had any previous training in massage? * Yes No If Yes, please describe: Health History Do you have any physical, mental or emotional conditions, including ut not limited to, injuries or disabilities that could affect or prevent you from performing any massage or bodyork techniques? * Yes No If Yes, please decribe Do You have or have you ever been diagnosed with a lower back condition, injury or disorder? * Yes No If Yes, please describe Do you now or have you ever been diagnosed as having any hand, arm or forearm condition or disorder? * Yes No If Yes, please describe Are you taking any perscribed medication that affect or impair your ability to participate in and complete the massage program? * Yes No If Yes, please describe Do you have a documented learning disability? * Yes No If Yes, please describe Do you knowingly have any communicable disease that can be transmitted by ethical touch? * Yes No If Yes, please describe Please list current medications * Please list all current prescribed medications Essay Essay Upload Drop a file here or click to upload Choose File Maximum upload size: 67.11MB Please write an essay to include the following 3 subjects: Why you would like to attend Full Circle? What you consider your strengths and challenges? Your professional goals? (150-250 words) Please enter what you would like to be your Username Current Face Picture We require a current face picture. This helps faculty and staff identify you when you come in for a visit or for class. Current Clear Face Picture Drop a file here or click to upload Choose File Maximum upload size: 67.11MB How did you hear about Full Circle Massage School How did you hear about Full Circle Massage School? * --Select One-- Full Circle Website Family/Friend Phone Book Word of mouth Event Advertisement Other Please be aware there is a $50 non- refundable application fee due before the first day of class. Thank you so much for your interest in Full Circle Massage School!!! Someone will be in contact with you as soon as possible. Please keep your username and password as this will become your access to future class content as a student. Acceptance of this application does not equate acceptance into the massage program.