Application

                      ENROLLMENT APPLICATION

Name_______________________________________________________________
              last                  first                        middle                                 maiden
Social Security #________________________ Phone #_______________________
Address______________________________________________________________
City_____________________________State_________________Zip____________
Date of Birth_________________________________Age_____________________
____Married____Single____Separated____Divorced____ Widowed
Spouse's Name________________________________________________________
Children #______________________ Ages_________________________________
Person to be contacted in case of emergency:
Name____________________________ Relationship________________________
Address______________________________________________________________
Phone #______________________________________________________________
Referred to School By__________________________________________________
Email Address (if applicable)____________________________________________

                                                           EMPLOYMENT
Present place of employment____________________________________________
Supervisor___________________________________Phone#__________________
Spouse's employment__________________________________________________
Supervisor__________________________________Phone#___________________

                                                             EDUCATION
High School Name_____________________________________________________
City_____________________________State________________Zip_____________
Graduate Year______________________GED______________________
College Name_________________________________________________________
City_____________________________State________________Zip_____________
Date attended_________________________________________________________
Did you graduate?_____Yes_____No
Degree held___________________________________________________________

                                              CLASS

Ankeny
Day_________8-12PM                                   Class date___________________

Night_________5:30-9:30PM                         Class date___________________

TUITION PAYMENT

_____Paying in full
_____3 Equal payments
_____Making monthly payments

I acknowledge I am physically, emotionally, and mentally able to participate in the massage therapy program.

Applicant's
Signature______________________________________________Date____________

                                                             REFERENCES

Please give two references not related to you.

Name__________________________________________________________________
Address________________________________________________________________
City_________________________________State_____________Zip______________

Name__________________________________________________________________
Address________________________________________________________________
City_________________________________State_____________Zip_______________

Mail completed application along with $50.00 non refundable application fee to:

                                    Iowa College of Natural Health
                                               1932 SW 3rd St,
                                           Ankeny, Iowa 50021

QUESTIONS:       CALL                  515-965-3991 OR 1-800-216-9418