I do hereby, on this day * , month * , year * enroll in the Therapeutic Massage Program at AQUARIAN AGE ALTERNATIVES, INC.  The total number of program hours is 500.

*First Name
*Last Name
*SS#
*Address
*City , *State , *Zip
*E-mail address
*Phone Number(Res)
Phone Number(Work)
Phone Number(Cell)
Referred by
Occupation
*Date of birth

A $100.00 enrollment/application fee will hold your place for our next class. The tuition balance is due at your first class. The tuition does not include text books, work books and other materials and charts needed for the class. There will be two make-up sessions for class time missed. Payment plans are available.

I understand that full tuition cost is;

Books	$450.00
Application Fee	$100.00
Tuition	$5,950.00
Total Enrollment Costs	$6,500.00

* I confirm that I have read and understand this enrollment agreement.

Complete & Print Enrollment Form before hitting the submit button!

Mail in the completed Enrollment Agreement with your $100.00 enrollment/ application fee payment.

(A printed version of this form will be presented for signature by the Student and the Director. )

Student: ___________________________________ Date: ______________

Director: ___________________________________ Date: ______________

This facility is accredeted and regulated by:

Indiana Commission on Proprietary Education

302 West Washington Street, Room E 201

Indianapolis, IN 46204

Toll Free Number 1 800-227-5695 (Indiana only)

317-232-1320

All Tuition and fees must be paid in full to receive grade transcript and/or Diploma.

* Required Information