Name:

Date:

Address:

City:

State:

Zip:

Home Phone #:

Cell Phone #:

Email

Sex:

MaleFemale

Date of birth:

Age:

SS#:

Are you a USA citizen?

YesNo

If not, Visa type:

Education Level:

High School DiplomaGEDCollege Degree

Year Graduated:

College Degree Type:

Emergency contact name:

Relationship:

Emergency contact Adress:

Emergency contact phone:

Is English your primary language?

YesNo

If not, what is?

Do you need any special accommodations in class?

YesNo

If yes, please explain:

Have you ever been convicted of felony or misemeanor other than traffic offense?

YesNo

If yes, please explain:

Which the following program are you interested?

Massage Class (Mon) Massage Class (Tue) Massage Class (Evening) Holistic Health Counselor Program

Class Start Date

I understand I must have a copy of my High School Diploma transcript or GED to endroll. I understand there will be $100 application fee and the application fee are non-refundable. This application will be reviewed by the school director, if you are not accepted by the school, you will receive full refund form you application fee. Falsif information on this application will be considered dismissal from this program and there will be no refund.

By signing below, I certify that had read and understand the refund policy. All information on this application are True & Correct.

Student Signature (type name):

Date:

Please include a $100 application fee, You can write the Check Alternative Care Solution. Send the application & Check to 3790 28th ST SW., Suite B, Grandville Mi 49418. Thank You