Hands-On Therapy Application for Admission

Please print legibly using black or blue ink.

Name                                                                                         

Address                                                                                      

City                                                      State         Zip                  

Home Phone (       )                              

Work Phone (       )                             

Cell Phone (       )                             

Email Address                                                                                         

SS#                                          TX DL#                                                    

Birth Date                                                 Male        Female      

Current Employment                                                                                         

Emergency Contact Person                                                                                         

Phone (       )                           

Relationship to Applicant                                                                                         

I am applying for these courses (check which applies)

      8 wk Day                Full Time Night

      16 wk Day               Part Time Night

      32 wk Day

Preferred Start Date of Program                                               

"In connection with my application, I understand that a consumer report containing public record information may be requested. This report may include the following types of information: names and dates of previous employers, credit information, bankruptcy proceedings, and other relevant information from federal, state, and other agencies both public and private. No charge is made to me to obtain this report."

(Your signature below indicates that the information on this application is true and accurate to the best of your knowledge and you authorize any party or agency contacted to furnish the above information.)

Signature                                                                                                                 Date

Please Note: This form must be accompanied by your $250 Deposit which is refundable based on school acceptance.

Mail this form along with your check to:

Hands-On Therapy

1804 N. Galloway Ave., Ste A

Mesquite, TX 75149

(972) 285-6133