Application for Admission

Name * First Last
Date of Birth * / MM / DD YYYY
Social Security Number *
Home Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone Number * - (###) - ### ####
Work Phone Number - (###) - ### ####
Cell Phone Number - (###) - ### ####
Emergency Contact Person
Emergency Contact Phone - (###) - ### ####
Primary Email *
Nearest Relative *
Nearest Relative Phone Number * - (###) - ### ####
When is the best time to reach you? * Morning 8am-12pm Day 12pm-5pm Evening 5pm-8pm
Name of High School/Secondary School *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Name of College (if any)
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Are you currently employed? * Yes No
If yes, please complete below.
Employer Name First Last
Employer's Phone Number - (###) - ### ####
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Position/Title
Admission Representative *
Do you have a computer? * Yes No
Which program are you applying to? *
The fee for admission to Institute of Integrative Healing is $25.00 (US currency). This fee is used to administer the entrance exam and to process your application, transcript requests, and financial assistance applications. If you are not accepted to Institute of Integrative Healing, your application fee will be refunded. Please fill out the Application Fee Authorization Form after you have submitted this application. Thank you.
How did you find out about our program? *
Personal Information
Previous Education * High School Some College College Degree Masters Degree Doctorate
Ethnicity *
Gender *
Marital Status *
Citizenship *
Annual Income *
Please read below for dependency status.
Are you dependent or independent? * Dependent Independent
Are you under the age of 18? *
If yes, please provide the full name of your parent or legal guardian:

Application for Admission

Application for Admission

Personal Information

Please read below for dependency status.