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APPLICATION FOR ADMISSION

North Eastern Institute of Whole Health

22 Bridge Street, Manchester NH, 03101
(603) 623-5018

A nonrefundable $50.00 Application Fee, must be submitted with your application!

Personal Information

Last Name
First Name
Street Address
City, State

Zip code
Mailing Address
City, State

Zip code
Phone
()		Email
Gender: Male  Female
Birth Date(mm/dd/yyyy)
 Clothing size
S   M   L   XL XXL XXXL
Birth Place
Maritial Status
Single   Married
Current Eployment
Citizen of US?
Yes   No
Position
Work Phone
()
Have you been treated for any medical or physical conditions other than colds or minor injuries in the last five years? Yes   No
If yes, describe:
Notify in case of emergency
Name
Phone
()
Street
City, State

Zip code
List two personal character references.
1.Name

Occupation
Phone
()
2.Name

Occupation
Phone
()
Previous experience and/or study in Massage or other Health Professions:
Why are you interested in Massage Therapy?
Have you ever been convicted of a felony or misdemeanor other than traffic offenses? Yes   No
If yes, describe:

Academic Information

High School(name, city, state)
GED/diploma(mandatory to apply)
Yes   No
College(name, city, state)

Program Information

I wish to enroll in the: 750-Hour Program 500-Hour Program*
for the: Sprng Semester Fall Semester

I wish to attend for: 13-Months 28-Months
*Leave blank if signing up for the 500-Hour program, which is less than 13 months

Please select your program choice:
Mon., Tues., Wed.:Morning   Evening

Morning classes are 8:30 AM - 1:00 PM
Evening classes are 5:30 PM - 10:00PM

Financial Information

How is your tuition going to be paid?
Self   Parent   Loan   Other
If other than self please print:
Name		Phone
()
Address
 City State Zip

A nonrefundable $50.00 Application Fee, must be submitted with your application!

North Eastern Institute of Whole Health does not discriminate against any applicant for race, color, religion, national origin, gender, sexual orientation, or age under provisions of State and Federal Laws.


or Print Application and send it with $50.00(please no cashe or 'starter' checks).