On-line Application

 Please fill out this form below and click "submit" when complete. You will be contacted and asked to pay a $75 (non-refundable) processing fee. In some cases, we may need additional information. Or, if you prefer, you can email us here and we'll gladly snail mail you an Application!
Request Date: ">

What class are you interested in

First Name Middle Last Name
Street Address
City State Zip Code
Home Phone

Area Code/Phone		 Work Phone

Area Code/Phone		 Cell Phone

Area Code/Phone
Email Address
Place of Birth: Date of Birth (mm/dd/yy):

Where and when did you complete High School?
Street, City, State, and Zip Code
Phone Number
If applicant’s high school records were maintained under a name different than that listed in item #1, state name used:

To be completed if applicant attended college or received other training.
College Attended From: To: Degree Attained

References: List two references other than family members:
Name Address Phone Number

Present occupation and employer

Job Experience: please indicate employment dates, job title, address, supervisor and phone numbers of your five most recent work experiences:

List any experience in a health-related field (not required for enrollment):

Do you have any physical or mental disabilities which may impair your ability to participate fully in all aspects of the CIMT program requirements?  
If yes, please explain:
Have you ever been convicted of a Felony?  
If yes, please explain:
Do you now have, or have you had in the past two years any contagious diseases?  
If yes, please explain (a physical exam may be required by a licensed MD):

How did you hear about our school?  

Please explaining your motivation for training in massage therapy and your philosophy of health care.

Please have your high school or latest college transcripts sent to our office: CIMT, 1490 W. Fillmore, Colorado Springs, CO 80904

Other considerations or comments you wish us to know about:

Have you ever been expelled or denied acceptance to a massage therapy or bodywork school?   

In case of emergency please contact:
Name Relationship Phone Number
Address
City State Zip Code

For security purposes, please enter into the box below the characters exactly as they are on the background (case-sensitive).