APPLICATION FORM

Name*

Current Street Address*

City*

Zip Code*

Email*

Age*

Date of Birth*

Sex*

Day / Evening Phone Numbers*

Do you usually finish what you start?*
YesNo

If accepted, are there any obstacles that preclude you from starting school?
YesNo

If so, what are they?

Are there any obstacles foreseen that may prevent you from completing the program?
YesNo

Do you have reliable transportation?
YesNo

Do you have dependable child care (if applicable)?
YesNoNot Applicable

How do you plan on paying for school?

If parents are paying for school, please complete their contact info

Name

Phone Numbers

State three reasons why you feel training at AIMM would benefit you: Reason One

Reason Two

Reason Three

State three reasons you want to become a medical massage therapist:

One

Reason Two

Reason Three

What type of place of employment do you envision yourself in following your graduation?