Equissage Colorado | Enrollment Application for Massage Therapy

Application

Print out the application and mail it with payment by credit card, personal check or money order to:

Equissage California
PO Box 2861 Valley Center, Ca. 92082

To pay via Pay Pal, indicate so at the bottom of the application and you will receive a request for payment in your email shortly after we receive the application. You can use a credit card to pay through pay pal, even if you do not have a pay pal account. If you want to pay for the cost of the entire course upfront please indicate so at the bottom of the application.

A $300.00 nonrefundable deposit is due with your application to hold your spot for the class dates you indicate. The balance is due the morning of the first day of class.

EQUINE SPORTS MASSAGE THERAPIST (ESMT)

E N R O L L M E N T A P P L I C A T I O N

PERSONAL INFORMATION

Date

Social Security #

Name

First

Last

Middle

Present Address

Street

City

State

Zip Code

Permanant Address

Street

City

State

Zip Code

Phone

Referred By

Are you 18 years of age or older? Yes No

EDUCATION

	Name and Location of School	Last Year Completed	Did You Graduate?	Subjects Studied and Degrees Received
Grammar

High School		1 2 3 4	Yes No

College		1 2 3 4	Yes No

Trade, Business or Correspondence School		1 2 3 4	Yes No

GENERAL Please limit responses to two lines. If you would like to provide more information, please do so on a seperate document.

Subjects of special study or interest

Horse-related activities

Why is a career as a ESMT of interest to you?

REFERENCES List below three persons not related to you, whom you have known at least one year

Name	Address	Position	Yrs. Acquainted

PAYMENT INFORMATION

Please accept my enrollment in the Equissage Certification Program in Equine Massage Therapy.

Enclosed is my check or money order in the non-refundable amount of $300.00 to cover the deposit for the class, starting //.

Additional payment information: