Charter College of Health and Massage Therapy

There are two approaches that can be taken to begin the application process. You can either download a copy of the application form or you can complete the form below. After submitting the application online, an email will be sent to you confirming the the form was sent (if you provided your email address).

This online form is only part of the application process. You will still need to send additional information, documents, and your application fee through the mail. The additional required steps will be described on the following screen after the form has been submitted.

(* - indicates a required field)

Personal Information

Applicant's Full Name
First Name:*
Middle Name:
Last Name:*
Gender:*	Male ........ Female
Date of Birth:*
Marital Status:*
Address:*
City:*
State:*
Zip:*	-
Phone (day):*	( ) -
Phone (evening):*	( ) -
Phone (cell):	( ) -
Email Address:

Current Employer:
Employer Address:
Employer City:
Employer State:
Job Title:
Years of Service:

Citizenship:*

Present State of Health:*
Do you have any health related problems that may interfere with massage?*	If yes, explain:
Do you have any or have had any communicable diseases in the past 2 years?*	If yes, explain:
Have you ever been convicted of a felony or misdemeanor, other than traffic violations?*	If yes, explain:

Emergency Contact Person
Full Name:*
Address:*
City:*
State:*
Zip:*	-
Phone Number:*	( ) -

Previous Education

Secondary Education
Name of High School:*
City:*
State:*
Year Graduated:*
If you are not a high school graduate, have you completed the GED requirement?	Date received:
College Education
Name of School:
Major:
Credits:
Date Graduated:
Degree Earned:
Vocational Training
Explain any of your vocational training:

Program Interest

Program Choice:*
Type of Student:*
Payment Options:*

Essay Questions

Why are you interested in becoming a massage therapist?*

What strengths and resources do you bring to this training?*

Do you have experience in any type of massage? If so, please explain.*

Have you ever been denied or have you ever surrendered a professional or occupational license, registration, or certificate? Explain:*

Describe your experience with massage therapy and its effect on your life.*

I hereby state that all of the information on this application is correct to the best of my knowledge.