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PROFESSIONAL CERTIFICATION PROGRAM APPLICATION

Fill in the form below and click "Submit" to send your application to us. Please be sure to fill in all (required) fields.

Personal Information:

First Name: Last Name: (required)

Address: (required)

City/Town: State/Province: (required)

Country: Zip/Postal Code: (required)

Phone (Day): - - Ext: (required)

Phone (Evening):  - - Ext:

Email Address: (required)

Educational Background: (required)

High School: Graduation Date: / /

College/University:

Major/Minor:

Degree: Graduation Date: / /

Post Graduate Degrees/Certificates:

Massage Therapy School: Graduation Date: / /

License/Certification: License Date: / /

Physical Therapy School:

License/Certification: License Date: / /

Professional Experience:

Please describe your current job, profession and/or practice:

Please describe your current work with (if applicable):

Humans:

Horses:

Please list your objectives for this professional certification program:

Please list your short and long term goals related to sports massage:

Short Term:

Long Term:

Please describe your experiences (if any) with horses outside the field of sports massage:

Sports massage is a physically demanding profession. Please note any physical limitations that could affect your performance:

References:

Please provide two professional references:

Reference 1:

Name:

Address:

Phone: (Day) - - Extension:

Email:

Reference 2:

Name:

Address:

Phone: (Day) - - Extension:

Email:

Training information:

Date(s) interested in attending training:

Do you need housing during the above dates?  Yes: No:

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