Your Future Is In Your Hands...
 

Institute of Health & Healing










Application For Admissions Form

Have a representative contact me!

Name: First:
Last: 
M.I.: 
Address: Street: 
City:
State:   ZIP:
Phone: Home: (xxx-xxx-xxxx format)
Work:
E-Mail:
Date Of Birth: (MM/DD/YYYY Format)
Social Security
Number:		 (xxx-xx-xxxx)
Massage and/or Health Profession Experience and Education:  List and briefly describe.  

Education Background
High School School:
City:
State: Year Graduated:
College School:
City:
State: Year Graduated:
Dates Attended From/To: /  Format:(MM/YYYY)
Degree:
Training/
Vocational School		 School:
City:
State Year Graduated
Dates Attended From/To: /  Format:(MM/YYYY)
Certificate/
Title 

Employment Background - Begin with the most recent

Current/Last Business Name:
Address:
City:
State: Phone:
Supervisor:
Employed From/To: /  (MM/YYYY)
Next Business Name:
Address:
City:
State: Phone:
Supervisor:
Employed From/To: / (MM/YYYY)
Next Business Name:
Address:
City:
State: Phone:
Supervisor:
Employed From/To: / (MM/YYYY)
Class Time Preference Day Classes
Evening Classes
Start Date  (Approximate MM/DD/YY)
Please tell us how you found out about the Institute of Health & Healing:


An enrollment fee of $50.00 is required before enrollment process is initiated.  This fee is non-refundable if accepted into the program.  This fee also ensures a hold on your place in class.  In the near future, a secured order form will be created to safely begin this process online.  In the meantime, we will call you after receipt of this form for payment details.  Thank you!

 
 
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11847 Canon Blvd., Suite 8, Newport News, VA  23606  (757) 873-3900