Lakeside School of Massage Therapy

Massage Therapy Benefits

Application for Enrollment

To apply, please fill out this form. You can either print it out and mail it to your selected campus with your application fee, or submit online and pay by credit card.
You will still need to mail the supporting documents.

If you have previously filled out an application, please do not submit a new one.

I am applying for classes at Lakeside in:
Milwaukee 1726 North First Street, Suite 200 · Milwaukee, WI 53212
Madison 6121 Odana Road · Madison, WI 53719

I am applying for the following class:
Fall 2008 30-week Day
Fall 2008 38-week Day
Fall 2008 52-week Evening
Winter 2009 30-week Day
Transfer into Associate Degree program

Full Name:

Mailing Address:

Address 1:
Address 2:
City:
State:
Zip Code:

Home Phone:

Work Phone:

E-mail Address:

Employment Status

Full Time Part Time Unemployed

Occupation:

Date of Birth:(MM/DD/YYYY)

Age:

Gender
MaleFemale

Are you eligible for Veterans Educational Benefits?

NoYes

Please enter the name and phone number of a contact person in the case of an emergency.
Contact Person:

EDUCATION AND BACKGROUND
(indicate name on school records if different)

High School:

College:

Technical or Vocational School:

Other Professional Courses:

Have you had an application for a health care license denied or withdrawn?
If yes, please explain:

Have you ever been in litigation connected with a health care practice?
If yes, please explain:

Have you ever been convicted of a felony? If yes, please explain:

HEALTH PROBLEMS (attach additional sheet if needed)

List any known medical conditions:

List any physical limitations that may affect your studies.

List any learning disabilities that would affect your studies.

Do you have any allergies? If yes, please list.

What has been your exposure to massage therapy?

How did you first hear about Lakeside School of Massage Therapy?

The following items will be needed to complete your application:

Proof of high school diploma or GED/State Certificate of High School Completion.
Transcripts from your most recently completed high school or post-secondary education.
Application fee of $25 (or pay online).
A 300-word typed explanation of your reasons for wanting to pursue a career in massage therapy, including a description of your career goals.
Two letters of recommendation from someone other than a family member.
A letter from a primary care physician stating that the prospective student is physically and emotionally capable to participate fully in the massage therapy program.
Proof of receiving a professional massage.
Evidence of immunity to measles, mumps and rubella.
Negative TB skin test or other evidence that applicant is free of active tuberculosis. (Test or evidence must be current within the past year.)

You need to submit a $25 application fee along with your application.