Step2: upload - Pacific Center for Awareness & Bodywork

Welcome back! Please complete the form to the right.

STEP 2: Biographical information

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"*" indicates required fields

Name*

First Last

Address*

We will not send anything to this address, nor will we sell or give any of your contact info to anyone else for any reason.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Gender*

Birthdate*

MM slash DD slash YYYY

Emergency Contact*

Name, Phone number, Relation to self

Year Applying For*

Highest Academic Education*

(Your answer does not affect your likelihood of acceptance into the program. We collect this only to observe demographic changes over time.)

Major Field(s) of Study

Photo*

Please upload a recent photograph of yourself--it's not relevant to the application, but it helps us remember you by putting a face to a name.

Max. file size: 512 MB.

High School*

Name, location, and graduation year

Previous Education

On separate lines, list all colleges, universities, and vocational schools etc. that you have attended (name, city, state, years attended, major, degree/certs)

Transcripts / Certifications

Please upload scanned copies of transcripts/certificates from any previous applicable training. They don't need to be official. Please name your file(s) with the format "Lastname-Transcript1". Do not pay anyone for this if you don't have them. Skip this step if it's not readily available.

Drop files here or

Max. file size: 512 MB.

Additional Training

Any additional information you would like to include regarding previous training and/or experience in related fields?

Current Job/Occupation

Employment History

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.

Philosophy of Health*

What is your philosophy of health and wellness? Length: One paragraph

Motivation for Attending*

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

Challenges and Growth Edges*

What are some primary physical or psychological challenges and growth edges that might be relevant for you while attending PCAB? Length: 1-2 paragraphs.

Challenging aspects at PCAB*

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.

Commitment*

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.

Experiences and Interests

Any relevant interests, experiences, or work during the last five years not mentioned earlier that provides a little more of a picture of you.

Trauma Diagnoses*

Have you ever been diagnosed with any of the following psychological conditions?

PTSD

cPTSD

Developmental Trauma Disorder

Personality Disorder Diagnoses*

Have you ever been diagnosed with any of the following personality disorders?

Borderline Personality Disorder

Narcissistic Personality Disorder

Anti-social Personality Disorder

Histrionic Personality Disorder

Paranoid Personality Disorder

Schizoid Personality Disorder

Avoidant Personality Disorder

Trauma, Therapy, and Stress*

What's your relationship with trauma? Have you ever seen a psychotherapist or counselor? If you are seeing one now, what is your plan while attending the course? If you have been diagnosed with a psychological condition in the past, to what extent do you believe it's relevant to your life now? Who or what do you rely on when experiencing significant stress?

Medications and Other Conditions*

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?

Yes

Medication Details

Please note that we do not exclude anyone based on medications. We also want to be adequately informed. If you take medications for psychological purposes, is there anything you'd like us to know that would help you feel supported.

Special Medical Conditions*

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.

Chemical Sensitivities

Multiple Allergies

Migraines

Chronic Fatigue Syndrome

Fibromyalgia

IBS/Digestive Issues

Wearing glasses at an early age

Sensitivity to cold

Anxiety/Depression

None of the Above

Convictions*

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?

Yes

Conviction Details

Please supply details.

Community Health Practices*

Do you wear face coverings and practice social distancing where it's required?

Yes

References: 1st email*

Please list the EMAIL addresses (NOT names or phone numbers) for three (non-family) references who have known you for at least 3 years. At least one reference should be a professional reference.

References: 2nd email*

References: 3rd email*

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.

I state that this application is complete, and all information is true.

Signature

Use your finger on your trackpad to create a signature. This won't work on a touchscreen device.

Typed Name*