THE INSTITUTE OF PROFESSIONAL PRACTICAL THERAPY
(Student Application Form)

1835 S La Cienega Blvd., Suite 260 l Los Angeles, CA 90035 l (310) 836-8811
5650 Vineland Avenue l North Hollywood, CA 91601 l (818) 995-8995

Prospective Class & Start Date: ____________________________________________________________

Full Name: ________________________________________________ Date of Birth: _____/_____/_____

Home Phone: ________________ Work Phone: _________________ Cell Phone: ___________________

E-mail Address: _____________________________________________________________________________

Home Address: _____________________________________________________________________________

City/State/Zip Code: ________________________________________________________________________

Driver’s License #: _____________________

In case of emergency, whom should we contact?

Name: _________________________________ Relationship: _______________ Phone: ____________

Name: _________________________________ Relationship: _______________ Phone: ____________

Have you ever worked in the Health Care field? Where? When? ____________________________ ___

Please describe any previous training in the Health Care field: _____________________________ _

Please describe, if any, previous work experience in the field of physical or massage therapy:

___________________________________________________________________________________ ______

What are your occupational and personal goals (for this training)? ____________________________

Do you have a high school diploma or GED? ________________________________________________

Are you eligible to work in the United States? _________________________________________________

How did you discover IPPT? ________________________________________________________________

What motivated you to choose IPPT? _________________________________________________________

- Please be advised that all students are required to give and receive massages during their courses.

- Please be advised that if you are suffering from any condition requiring medical attention, please consult your physician prior to starting courses. It is pertinent to find out whether or not this condition will impede upon you in receiving or providing massages at the school.

- Please be advised that if you have been convicted of a felony, you should contact the appropriate licensing organization and inquire about licensing.

- Please be advised that if you are suffering from a sexually transmitted disease or any other communicable disease (HIV, AIDS, etc), please be sure to contact the appropriate licensing organizations to inquire about licensing and how it may affect you.

- Please be advised that job assistance is only available for individuals who are eligible to work in the United States. The institute cannot guarantee employment to students or graduates. 

- Please be advised that The Institute of Professional Practical Therapy does not provide student visas, housing or housing assistance to students. Students from other states or countries who come specifically to take courses from the IPPT do so at their own risk.

Signature: ______________________________________________________ Date: ________________________________________

*Upon enrolling in a course at IPPT, please provide the school with a copy of your driver’s license or any other equivalent picture identification. We must verify that you are the individual who is enrolled at The Institute of Professional Practical Therapy.