Employer		Job Title
Employer's Address
Supervisor's Name		Phone
Emergency Contact		Phone

Program Applying For	Click Here To Select Morning Afternoon Night
Start Date
Completion Date
How did you hear about Universal?

A copy of your high school diploma or GED should be sent to the school. We do not accept ability to benefit students.
Date of Graduation
Certificate Received	Click Here To Select Diploma GED

Are you a U.S. Citizen?	Yes	No
If no, please provide immigration documentation.

Non-Discriminatory Policy Universal Therapeutic Massage Institute, Inc. welcomes students of any race, color, national and ethnic origin or sexual orientation. Confidential Information The information requested in this survey will be used by Universal Therapeutic Massage Institute, Inc. in compliance with state and federal reports on enrollment and to support institutional affirmative action efforts. Refusal to provide any of the requestion information will not subject you to any adverse treatment; however, because of the importance of the survey, we urge your conscientious participation. Thank you.

Complete the following information by checking the appropriate item.
Gender:	Male	Female
GED?	Yes   No	Year
High school diploma?	Yes   No	Year
Associate degree?	Yes   No	Year
Four-year degree?	Yes   No	Year
Predominant ethnic background:	White	Black
	Hispanic	American Indian
	Alaskan Native	Asian or Pacific Islander

1. Do you have any disabilities that we should be aware of? If so, please explain.

2. Have you ever been convicted of a felony? If so, please explain.

3. Have you ever received a professional massage before?    Yes   No

4. Do you have any learning disabilities, psychological or emotional challenges that could interfere with your ability to complete this program? If so, please explain.

5. Would you be comfortable giving and receiving massage by both men and women?    Yes   No

6. Have you received any previous training in the field of bodywork? If so, please describe that training.

7. Please fill out the following health history by checking any conditions that apply to you.
Serious Injuries	Bursitis
Back Pain	Headaches
Allergies	Arthritis
Skin Infection	AIDS_ARC
Recent Surgery	Diabetes
Alcoholism	Cancer
High Blood Pressure	Low Blood Pressure
Stroke	Varicose Veins
Heart Conditions	Seizures
MS	Tuberculosis
Mononucleosis	Pregnant
Dyslexia	Herpes
Drug Abuse	Hepititis
Multiple Chemical Sensitivity