Student Application

To reserve your space in class, please complete the online form below and then select this link to pay your $100 non-refundable fee.

If you prefer to mail your application, please print and complete this form. You can then mail the form with a check to: Advanced Massage Therapeutics 2221 Goldsmith Ln. Louisville, KY 40218

Name *

First

Middle

Last

Street Address *

City, State Zip *

Email *

Date of Birth *

Personal Phone Number *

Work or Alternate Phone Number

Occupation *

How Did You Hear About Us? *

Reason for Taking the Class *

Past Education with Massage? *

• Yes
• No

If Yes, Explain Below

Which Class Do You Prefer? *

• Daytime
• Evening

Non-Refundable Fee *

• I will pay via Credit Card/PayPal
• I will mail a check to the address below

Terms of Agreement *

• Yes, I understand the terms

By checking above, you are indicating all information above is correct and you understand a $100 Non-Refundable fee is required.

Submit

Select this link to pay the $100 non-refundable fee.
Or, you can mail a check to: Advanced Massage Therapeutics 2221 Goldsmith Ln. Louisville, KY 40218