Online Application Online Application Name * Name First Name First Name Last Name Last Name Phone * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email * I am at least 16 years of age: Yes / No would you be interested in a free health evaluation from a natural health student? Yes / No (this is part of the student curriculum and will be scheduled like the massage labs - regular cost is $99) As a professional school for Natural Health, Massage, Bodywork Therapy, and Holistic Doulas, we are looking for Professional Student Massage Clients to assist our students in their learning process. To give our students a "real Jife" experience in their field, we need clients of all shapes, sizes, ages, and abilities. Not only does it help our students and staff to have you as part of this process, it is an amazing experience for you. It's a perfect way to introduce yourself to new thera.pies, relax, and help a student on their path to success; all for only $20! However, there are a few requirements that you must meet in order to qualify to be a Professional Student Massage Client. Please read carefully and initial each of the following to verify that you meet the requirements and sign the form on the reverse side to be considered. [267] As a Student Client: * I agree to pay a $20 non-refundable fee prior to the appointment. This fee is used as a donation to our non-profit Naturopathic Community Center, which allows us to provide these and other services I agree to show up for my scheduled appointment at least ten minutes early. I agree to turn my cell phone OFF and to not eat during the therapy. I agree to receive therapy from any student, regardless of gender. I acknowledge that I can climb a flight of stairs. If I must cancel my appointment, I agree to do so at least 48 hours in advance (or as soon as possible in an emergency situation). I acknowledge that two cancellations or a No Call No Show will cause me to be removed from the Professional Student Massage Client List. I acknowledge I am not allowed to bring my children and leave them unattended during my session. I acknowledge I will need to disrobe (in privacy) to my underwear for certain therapies. No swimming suits or exercise attire allowed. I acknowledge that tipping the student for their time and effort is encouraged and appreciated, but not required. I acknowledge that sometimes students have unforeseen circumstances that prevent their attendance. Every effort will be made to notify you as early as possible if this occurs. In the rare instance a student is unable to attend a session, I agree not to show anger/frustration toward the "bearer of bad news." I understand that student therapists are assigned to clients by the instructor prior to my arrival, and my attendance is necessary in order for the student to complete their required hours. I understand that student therapists are applying overall health practices for the assigned lab, and that they are not tailored to individuals (though students may inquire about areas of concern). I agree to receive any of the following therapies: (Please check all that apply) * Massage: Massage often involves full body, i.e., neck, back, arms, shoulders, and legs, to loosen & relax muscular tension, help with flexibility, boost immune system, and improve attitude. CranioSacral: During this therapy, you relax fully-clothed on a massage table while the therapist uses a light touch to hold points of tension along the sacrum and spine and ori the cranium. This helps to improve the flow of fluid that nourishes the nerves that affect the function of every body system. Reflexology: This therapy will focus on your feet; reflexing the 7200 nerve endings to increase circulation, work out areas of tension and congestion, relieve pain, and promote your well being. Light Healing Touch: Designed to reduce stress and negativity from others as well as pollution from cell phones, computers, etc.; this unique and popular therapy uses light touch and the space around your body to remove congestion in and around your body, greatly improving mental clarity, energy, drive, and optimism. If you meet the professional student massage client requirements, you will be added to the Professional Student Massage Client Call List and contacted as scheduling begins. Please remember, these courses are an important part of our students' education, and your attendance is crucial to their success. A receipt of my $20 donation will be given at time of session/payment. I have read and understand this information. * signature keyboard Clear Date * Do not write in area below I for staff use only Approved By * Date Notes: DB - LT - CL - EM * Initials * Date If you are human, leave this field blank. Next
