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Ogden Institute of
Massage Therapy

APPLICATION FORM
Massage Therapist Certificate Program

Student Name

SSN

Date of Birth

Phone #

Address

City

State

ZIP

E-mail

Cell Phone #

Work Phone

Occupation

Applying for Class #

Start Date

End Date

 

Privacy Act of 1974 Statement

To protect the privacy of students and families, federal law sets certain conditions on the disclosure of personal information from records kept by schools that participate in the FSA programs. The relevant law is the Family Educational Rights and Privacy Act of 1974. OIMT treats student records in accordance with FERPA laws and statutes. Your responses are completely confidential. Providing the information is voluntary; however, failure to disclose the information may result in not being admitted to the School.

Please answer the following on a separate sheet of paper.

  1. What is your purpose for enrolling in this training program? What do you hope to gain from your participation? Do you plan on making Massage Therapy a career?
  1. Briefly describe your work and life experience during the past five years. Describe your academic background. List schools, graduation dates, degrees, honors, etc. Preferably include a resume.
  1. What prior experience or training have you had in massage therapy or other health care practices? Include workshops, formal training, apprenticeships, etc.
  1. Have you received a massage from a licensed massage therapist or some other form of bodywork before? Please explain.
  1. Describe how you plan to budget the time that you will need to meet the requirements of the program? (Both in and out of class)
  1. How will this program fit into the other aspects of your life and what kind of personal support system do you have?
  1. If you are accepted into this program, describe how you plan to finance your tuition and your training expenses.
  1. Have you ever been convicted of a crime? If yes, please give explain: (NOTE: This information is requested because the program will lead to a professional occupational license and some convictions may prevent or delay the eligibility to hold a license.)
  1. How did you find out about this school and what prompted you to choose the Ogden Institute of Massage Therapy?
  1. Are you currently in good health? Are you free of any communicable disease? Describe any existing physical, emotional or mental conditions that may affect your studies or participation at OIMT.

Statement of Health

I, the undersigned, do hereby attest that, to the best of my knowledge, I am in adequate health. I am free of physical or mental illness that may inhibit my ability to perform the duties of a Massage Therapist. I am free of all communicable or mental Diseases that may put another human being at risk of harm.

Signature:

Date:

I verify that all the information included in this application is accurate and true to the best of my knowledge.

Signature:

Date:

Please bring or send the following to:

Ogden Institute of Massage Therapy
3500 Harrison Blvd. Suite #102
Ogden, Utah 84403

  1. Completed application form
  2. Copy of high school diploma, GED, or college diploma
  3. Photograph of yourself
  4. Letter of recommendation
  5. $100.00 application fee

WE LOOK FORWARD TO HEARING FROM YOU!