Massage Therapy Program Application

Massage Therapy Program Application

Alamance Community College
Hello!

Thank you for your interest in Alamance Community College Massage Therapy Program. You’ve picked a great time to pursue a career in this growing and rewarding field of work. Our program is science-based, providing a solid foundation to begin a professional pathway that is uniquely your own.

Your first step is to complete this application, collect the required documentation, and schedule an admission interview with the ACC Massage Therapy Director, Joseph E Zajkowski Wright; email jewright050@alamancecc.edu or call (336) 532-5018. Please see below for a list of the required documentation you must present upon arrival for the interview.
PERSONAL INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOtherPrefer not to say
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email*
example@example.com
EMERGENCY CONTACT
Name of Emergency Contact*

First NameLast Name
Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Email (if available)
example@example.com
EDUCATION BACKGROUND
High School Diploma or GED:*

YesNo
Year Graduated
School
Dates Attended
Degree/Certification
EMPLOYMENT HISTORY (Optional)
Employer
Job Title
Dates Employed
Responsibilities
HEALTH & BACKGROUND
Do you have any physical conditions that may affect your ability to perform massage therapy?*

YesNo
If yes, please explain.*
Have you ever been convicted of a felony?*

YesNo
If yes, please explain.*
Are you currently CPR/First Aid certified?*

YesNo
Yes — Expiration*
SHORT ANSWER QUESTIONS
Why do you want to pursue a career in massage therapy?*
What qualities do you possess that will help you succeed in this field?*
What are your professional goals after graduation?*
DOCUMENTS YOU MUST BRING TO YOUR INTERVIEW
- Copy of High School or College Transcripts, Diploma or GED
- Government-issued photo ID
- Background Check (available at your local Clerk of Courts office)
- This completed application
Declaration

I hereby certify that the information provided in this application is true and complete to the best of my knowledge. I understand that falsification may result in denial or dismissal from the program.
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Massage Therapy Program Application

PERSONAL INFORMATION

EMERGENCY CONTACT

EDUCATION BACKGROUND

EMPLOYMENT HISTORY (Optional)

HEALTH & BACKGROUND

SHORT ANSWER QUESTIONS

DOCUMENTS YOU MUST BRING TO YOUR INTERVIEW

Declaration