Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Gender
*
Birthdate
*
MM
DD
YYYY
Emergency Contact (Name, Phone number, Relation to self)
*
Year Applying For
*
Highest Academic Education
*
High School (Name, location, and graduation year)
*
Current Job/Occupation
*
Please give us a brief sense of your recent work history (title, location, duration). We are not checking details--this is just to give us more of a sense of you.
*
Any additional information you would like to include regarding previous training and/or experience in related fields?
What is your motivation for attending a massage therapy program, and PCAB specifically? In particular, what do you hope to gain, personally and professionally, by attending PCAB? Is there a backstory that brought you to this point? Length: 1-3 paragraphs
*
What are some primary physical or psychological challenges and growth edges that might be relevant for you while attending PCAB? Length: 1-2 paragraphs.
*
Please comment on A) How easy is it for you to connect with other people? B) How comfortable you feel in groups or social situations, C) How you feel towards people who express themselves emotionally, and D) How well you respond to feedback.
*
Because the quality of the program depends a lot on the quality of the class container, we are seeking students who are dedicated to co-maintaining a safe and rich classroom container, who aspire to resolve conflicts in a proactive and healthy way, and who understand that their individual actions affect the class as a whole. We want students who are both punctual and internally engaged in both the bodywork and relational portions of the program, which may involve being with feelings that may not be pleasant or comfortable sometimes. Please comment on this with as many words as needed.
*
Any relevant interests, experiences, or work during the last five years not mentioned earlier that provides a little more of a picture of you.
*
What's your relationship with trauma and stress-related disorders? Have you ever seen a psychotherapist or counselor? If you are seeing one now, what is your plan while attending the course? Who or what do you rely on when experiencing significant stress?
*
What is your definition of "trauma-informed"? What expectations do you have about what a trauma-informed massage school will be like?
*
Have you ever been diagnosed with any of the following psychological conditions?
*
Have you ever been diagnosed with any of the following personality disorders? *
*
If you checked "other" in either of the previous 2 questions, please describe below
Are you currently or have you been in the last five years under a doctor’s care, or taking medications for any physical or mental/emotional condition?
*
Please check all of the following that apply to you. These conditions do not exclude you from the program, but they assist us in having a more informed discussion with you about your life and your life's challenges.
Are you currently charged or have you ever been convicted or found guilty of violating any federal, state or municipal ordinances other than traffic or other minor offenses?
*
References: 1st email
*
References: 2nd email
*
References: 3rd email
*
General Agreement
*
By checking the box below, I am acknowledging and agree with the following:
I have completed all questions to the best of my knowledge and I state that the information given here is true and correct. The practice of massage therapy is a demanding profession, and I verify that I have considered my health and my ability to complete a program in massage therapy at the PCAB. Furthermore, I understand that this is a very intensive program and that tuition is not refundable unless there is a qualifying medical emergency involving myself or an immediate family member. I have answered the medical questions to the best of my knowledge and I state that the information here is true and correct. I understand that all times and dates are subject to revision, and that I am not considered registered until I have paid the application and registration fees and received an acceptance letter. Prior to final acceptance in the program, an interview with the Director may be required.
Refund Agreement
*
By checking this box, I am acknowledging and agree with the following refund policy: The following policies apply to all programs offered by PCAB: The following policies apply to all programs offered by PCAB:
1. The application fee of $100 and registration fee of $2,250 are non-refundable.
2. If for any reason an applicant cannot attend for the year they applied and were accepted for, they may defer their enrollment. Application fee and registration fee may transfer to a future program. PCAB reserves the right to change or cancel future programming at any time.
3. A student who cancels or is dismissed during the first half of the program is responsible for a prorated tuition amount based on the percentage of weeks enrolled. A student who cancels or is dismissed during the second half of the program owes the full tuition amount and no refunds will be granted.
4. All tuition refunds incur a $500 processing fee.
5. Official notice of withdrawal shall be given to PCAB in writing, or the date of withdrawal is considered to be fourteen (14) days after the last date of attendance. Any payments owed from that date would become due immediately.
6. Nonrefundable payments remain nonrefundable regardless of the reason for cancellation or dismissal.
7. A student forfeits a prorated refund if their cancelling or dismissal brings the class enrollment to below operational levels.
8. Any refund owed to the student will be made within thirty (30) days after receiving notice of cancellation or dismissal.
9. No refunds are given for books, supplies, or any costs not paid to the school.
10. A fee of $25 will be charged on any check returned for insufficient funds, and only cash, credit card, or digital payments will be accepted thereafter.
12. When payments are made, payments will be applied to late fees and payment fees first, and any remaining amount will be applied towards the tuition.
13. Any balance owed from a previous PCAB course, sessions, or supplies must be paid in full before any payment plan for this course will be considered.
14. Failure to submit minimum tuition payments within five (5) calendar days from their due date will result in suspension from the program until payment is made. Failure to submit minimum payments within ten (10) calendar days from their due date will result in permanent dismissal from the program.
15. A student will be permanently dismissed from the program if a late payment is returned due to insufficient funds.
16. Unpaid student debt will be sent to a collections agency or taken to court upon dismissal. Students will be responsible for any and all fees or costs associated with either process.
17. Any classroom or clinic hours missed during suspension will register as unexcused absences whose hours cannot be acquired by any means.
18. Should PCAB deem it necessary to cancel or postpone the program due to lack of enrollment or other reason, a full refund of all monies paid (except the application fee) will be automatically given, and PCAB will have no further obligation. Every attempt will be made to inform the student of cancellation or postponement in a timely manner.
19. All monies owed must be paid in full and all coursework completed before a student may graduate from the course and receive any transcript or certificate of completion.
20. In case of illness, disabling accident, death in the immediate family, or other circumstances beyond the control of the student that cause the student to withdraw from school or in case of PCAB terminating the student’s enrollment for any reason, the school at its sole discretion may arrange a tuition settlement that is reasonable and fair to both parties.
Waiver and Release of Liability
*
I am aware that while attending school at The Pacific Center for Awareness & Bodywork (PCAB), I will be practicing and receiving massage, as well as participating in physical exercises and movement of various forms. I hereby give permission to staff and students to interact with me to facilitate my growth and education. I am aware that this includes touch, verbal processes, conversation of various kinds, as well as bodywork and movement techniques. I hereby release from liability, and hold harmless, all staff & students who may interact with me in these ways. I choose to attend school and be on the premises, including driveways, parking areas, walking trails, yards, and where classes will be held. I agree to be responsible for my own wellbeing and safety. I hereby hold harmless and release from liability Alison Fields, The Church of the Pacific, any and all staff, other students at the school, By Aliki LLC, and the Pacific Center for Awareness & Bodywork for any injury, illness, damage to my self or my personal property, or any loss I may incur while on the premises while attending classes at any of PCAB’s facilities.
Waiver and Release from Psychological Liability
*
I understand the following: 1. The Pacific Center for Awareness and Bodywork (PCAB) is a massage therapy school that offers a pre-licensing program that exists for the purpose of training future massage therapists. 2. Both massage therapy and mindfulness practices have psychological impacts. PCAB’s training program is designed to properly educate students about these impacts and how to best address them. 3. Because massage and mindfulness have psychological impacts, PCAB teaches ways to provide self-care, and PCAB also encourages students to find support from psychological professionals if necessary. Therefore, I will not hold PCAB or any of its staff or instructors liable for any psychological harm or distress resulting from participating in the program. 4. No part of PCAB’s massage therapy program (including the communication and mindfulness tools and exercises) constitutes or implies psychotherapy or counseling services, nor psychotherapy or counseling training. Talking with an instructor, including instructors who are also licensed psychotherapists and counselors, inside or outside of class, does not constitute psychotherapy or counseling. 5. PCAB does not provide psychological services. Therefore, I will not hold PCAB or any of its staff or instructors liable for not providing psychological services, and I will not make claims that psychological services were provided. 6. It is the student’s responsibility to assess whether s/he needs psychological support and to seek out that psychological support outside of school. Therefore, if I want or need to seek out psychological support, I will do so on my own.
Participant Agreement
*
I understand all of the following: • PCAB’s Bodywork Program has a dual focus as a personal growth and professional development program. Both aspects of the program focus on the healing of the body, mind, and heart through a biopsychosocial approach. The program offers training in several bodywork modalities and also incorporates many opportunities for deep personal exploration of feelings, beliefs, patterns, communication strategies, and the nature of the Self. • The program proceeds from basic skills to advanced skills at an accelerated pace. Both the content and the pace of the course can be physically and emotionally challenging at times for some. • Each participant will be a unique and integral part of a unique whole. Reliable attendance and timeliness are important because they both affect the total number of hours that one will graduate with, and one must graduate with 740 hours in order to ensure that one has all necessary hours to qualify for licensing in every state. More importantly, reliable attendance and timeliness also affects the quality of the classroom experience for everyone. • We will be practicing various biopsychosocial therapies/modalities with each other. Though the class and the staff provide a supportive environment for personal growth, the consciousness sessions in class are not a replacement for sessions with a professional counselor or psychotherapist. It is recommended that every student consider finding extra psychological support outside the program during the program to get the most out of the program possible. • The latter half of the bodywork portion of the course provides an extensive introduction to Structural Integration (SI). It does not constitute a comprehensive training in this modality. One should seek further education after graduation in order to ethically market oneself as an SI practitioner. • As a participant, I commit to all of the following: • Giving my utmost to both the personal and professional aspects of the program. • Showing up to ALL classes daily and on time (unless prevented from doing so by illness or emergency, or previously excused by the Director). • Participating in both the physical and consciousness-oriented therapies. • Studying/practicing outside of class and completing all assignments. • Behaving in a way that does not jeopardize the physical or psychological safety (conscious or non-conscious) of fellow classmates. • Being as authentic and compassionate with myself and others as I’m able. • Being a full participant in all of the above, and supporting other classmates in doing the same. I understand that as part of my commitment to all of the above, I welcome staff to engage me in a compassionate discussion if I am failing to uphold any part of this agreement, and I understand that continued failure in this regard may be grounds for dismissal from the program.
Photo, Video, and Audio Release
*
This is to confirm that I hereby give permission to Pacific Center for Awareness & Bodywork, and its Director, to use images and/or recordings of me that were taken during my participation in any of the courses or trainings presented by them. This includes the following: photos, video, audio, and any recordings taken by any other means. If I don’t want a specific photo, video, or audio used, I will specify this request on the day of the recording. I understand that any such material may be used for advertising and promotion purposes and/or educational materials only.
Application Payment $100
*
After submitting this form you will be automatically taken to the application payment. Payment MUST be submitted for your application to be considered.
The $100 application fee is non-refundable. After we receive your application, we will set up a phone interview. If you are accepted into the program, a non-refundable registration fee of $2,250 is due within 14 days to secure your position in the program.
Signature/Typed Name
*
