Pennsylvania Institute of Massage Therapy
Application for Admission
(Applicant must 18 years of age or older)

Name:         Date:
Address:
City:        State:   Zip:
Home Phone:    Work Phone:   
                                                                         e-mail:

Class Preference:    Day    Evening    Weekend
I would like begin classes on the nearest start date to January (Day, Evening, or Weekend) March (Day or Evening) June (Day or Evening) October (Day, Evening)

Highest Credential Earned:
G.E.D. or Equivalent   High School Diploma   College Degree
M.D.   D.C.   D.M.D./D.D.S.   D.P.M.   R.N.   P.T.

If you have ever been convicted of a crime, please click here

If you have a physical or emotional condition which would impair your ability to give or receive massage, please click here

Why do you want to study Massage Therapy?


What do you expect to learn during this course of study?