Application Form

Application Form
Before completing this form you should have:

Reviewed all of the details regarding the course or your choice.
Ensured that you have all the entry requirements for the course of your choice
You have read the Additional Information and Costs Here.
Read the Terms and Conditions Here

Personal Details

Name:

Address:

Email Address:

Phone Number:

Mobile Number:

Date of Birth:

Next of Kin:

Next of Kin Phone Number:




		Please insert your name as you would like it to appear on your diploma

Educational Details

Highest Level of Education:

Occupation

Do you hold a qualification in any complementary therapy?

Why are you interested in enrolling for the course?

How did you hear about us?

Health Details

Course Selection

Please indicate which course you are applying for and, where relevant, which venue you wish to attend.


	Anatomy, Physiology and Holistic Massage

Galway Saturdays

Limerick Sundays

Limerick Monday Evenings


	Sports Injury Therapy Diploma

Galway Saturdays

Limerick Sundays

Limerick Thursday Evenings


	Sports Equipment Diploma


	Limerick Tuesday Evenings & Weekends


	Diet and Nutrition Diploma


	Limerick Saturdays


	Size of Institute uniform you wish to order:


	Small


	Medium


	Large


	X Large


	XX Large

Declaration by the Applicant:

Your signature indicates that the information you have provided is true and complete and that you have read, understood and agreed to be bound by the terms and conditions of the Institute.

Signature: ______________________________________ Date: ________________________________

PLEASE PRINT THIS FORM and return with your deposit of €400, by postal order, bank draft or cheque, made payable to The Institute of Massage and Sports Therapy to:
Programme Director,
Institute of Massage and Sports Therapy Ltd.,
Ballyhane,
Birdhill,
Co. Tipperary.

We look forward to meeting you.

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