Chandler-Gilbert Community College

Therapeutic Massage Program Application

Desired Start: Fall 20___

Name______

LastFirstMiddle

Former or Maiden name(s)that may identify transcripts______

Student ID#______Phone(______) ______- ______

email______

Mailing Address

______

StreetCityStateZip

Current Occupation/Employer______

Have youworked in a Health Care setting before? Yes No

Have you completed(or will you by thefall semester) all 6 prerequisite classes?

Yes No

  • BIO160
  • WED151
  • WED165
  • WED215
  • HCC130
  • HCC145AA

Check each level of education completed: GED High School Diploma AA Degree Other

Please specify any degree beyond high school

______

Therapeutic Massage Goal: Certificate of Completion (CCL) Associates Degree (AAS)

List name and location of each college attended

CollegeCity and State Dates Attended

I certify that:

  1. All information provided by me is true, correct, and complete.
  2. It is my responsibility to provide all requested information to complete my file. Failure to provide all requested information may adversely affect my evaluation.
  3. Admission into program is conditional until I have successfully completed all requirements.

______

Applicant Signature Date

Therapeutic Massage (TM) Program Requirements

Acceptance into the Program

  1. Meet all CGCC acceptance requirements
  2. Meet with Program Coordinator
  3. Complete all program prerequisite classes with a “C” or better grade
  4. Submit this application form
  5. Interview with the ProgramCommittee – to be scheduled

Beginning the Program

  1. Attend program cohort meeting after being accepted
  2. Summer Paperwork – discussed at program cohort meeting
  3. Immunizations
  4. Health declaration from physician
  5. TB skin Test
  6. CPR for the Health Care Provider
  7. Fingerprint card
  8. Drug screening

4. Register for WED230 & WED231 (Program Coordinator signature required)

Please submit all paperwork to:

Dr. Gregory A. Trone, Therapeutic Massage Program Coordinator

Office: CGCC Pecos Campus Estrella Hall #215

Phone: (480) 732-7289

Email:

Chandler-Gilbert Community College, 2626 E. Pecos Rd., Chandler, AZ 85225

A Maricopa County Community College

The Maricopa County Community College District (MCCCD) is an EEO/AA institution