Application for Black Brook School of Massage

Begin your journey to Create your Future with Us. Please fill out the application if you would like to attend one of our next classes.

To ensure proper consideration, please fill in the information below as completely and accurately as possible.

After your application is received you will have an interview with the director of the school. This interview will ensure that you have all of your questions answered and all of your responsibilities have been explained.

Today's Date:

Personal Information

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Phone *

Email Address *

Date of Birth *

Are you a citizen of the United States? *

Yes

No

Do you have a High School Diploma or GED? *

Yes

No

If you attended College, please list which one and the years attended.

If you attended Technical School, please list which one and the years attended.

Have you ever attended massage school in the past?

Yes

No

Why did you leave massage school?

Have you ever been convicted of a felony?

Yes

No

If yes, please explain.

I understand that the State Of Arkansas Department of Health requires the following before I can apply for my Arkansas massage license: 1. Must be 18 years of age or older. 2. Must have a high school diploma or college transcript that can be submitted. 3. Must be a US citizen or have a green card. 4. Must Complete a background check (As of Aug 1st, 2023 this will be needed before the start of class). *

Yes

No

Employer 1

Phone

Start Date +

End Date +

Position

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

No

Phone Number

Availability

Which days of the week are best for you to attend class? Pick only Wednesday/Thursday OR Saturday and Sunday. *

Wednesday

Thursday

Saturday

Sunday

Confidential and Personal information

Practicing massage therapy requires physical stamina and flexibility. Practitioners are required to stand for long periods of time - 1 1/2 hours, have strong flexible joints, (wrists, elbows, ankles, and knees) and sit comfortably. We ask that you inform us of any physical issues you have that require special accommodations. Medical Conditions: (Please check all the medical conditions occurring currently or within the last two years.

Are you currently taking any medications? What is their purpose?

Do you have a physical disability such as visual impairment, hearing impairment, etc. A learning disability such as ADD, ADHD, and/or a psychiatric disability (e.g. depression, bipolar, panic disorder, etc.) that could require special accommodation by Black Brook School. Note: information requiring disabilities is not requested for acceptance purposes.

Do you have any previous experience in the fields of the healing arts or massage?

Why do you think being a massage therapist would be a good fit for you?

How did you hear about our school and why did you choose us? *

What is your preferred focus (i.e. sports massage? relaxation? eldercare? prenatal? women? special needs clients? etc.)

What would be your dream job in this career? Where do you see yourself in 5 years?

What might concern you about attending massage therapy school and completing the curriculum? *

Is there any aspect of your personality that you feel needs improvement? *

Yes

No

Briefly describe your interests and how you would be an asset to Black Brook School of Massage.

Ankle/ foot pain	Shoulder pain
Carpal Tunnel syndrome	Elbow or arm pain
Knee pain	Back pain
Skin conditions	Wrist or hand pain
Hip/ leg pain	Neck pain
Other Other