<p> Blue Lotus Thai Healing Studies Application for Admission </p><p>A complete application must include: This application form filled out completely and emailed to: [email protected] or mailed to: Blue Lotus Thai Healing Studies PO Box 6046 Lindenhurst, IL 60046</p><p>$400 Deposit. Check made out to Blue Lotus Thai Healing Studies and mailed to the PO Box above, or credit card as stated at the end of this application.</p><p>Once we review your completed application and deposit, we will contact you for a phone interview. ______</p><p>General Information</p><p>Date of application ______Program Location ______</p><p>School Start Date: Month ______Year ______</p><p>First Name ______Last Name ______</p><p>Address: Street ______</p><p>City ______State______Zip______</p><p>Cell Phone (______)______Home Phone: (_____)______</p><p>Email ______</p><p>Birthdate______</p><p>Emergency Contact</p><p>First Name ______Last Name ______</p><p>Cell Phone (_____)______Home Phone (_____)______</p><p>Initials______www.bluelotusthai.com Page 1 Introduction to Blue Lotus How did you first learn about Blue Lotus? ______</p><p>If you looked up our website, what search words did you enter? ______</p><p>If there is a specific individual who recommended you to Blue Lotus, please write their name below. ______</p><p>What were important factors in making your decision to apply? ______</p><p>Education</p><p>High School ______Location ______Graduation Year ______College / University______Location______Dates Attended ______Degree Earned ______Major ______Other Training / Education / Degrees (Please include any certifications or training you may have received in bodywork, yoga, alternative medicine or therapies or training in any other fields) ______</p><p>Previous / Current Education or Experience with Thai Massage ______</p><p>Previous / Current Education or Experience with General Bodywork ______</p><p>Skills / Hobbies / Interests ______</p><p>Initials______www.bluelotusthai.com Page 2 ______</p><p>Experience with Thai bodywork / Meditation</p><p>Have you received a Thai bodywork session before? Yes_____ No_____</p><p>Have you been to Thailand or Southeast Asia? If yes, where and when? ______</p><p>Previous / Current Education or Experience with Meditation? If yes, please describe. ______</p><p>Are you open to learning a form of meditation that comes from the type of Buddhism practiced in Thailand? Yes __No__</p><p>Previous / Current Education or Experience with Yoga (If so, please state type of yoga practiced, main teacher(s) and for how long) ______</p><p>Previous / Current Education or Experience with other Asian modalities such as Tai Chi or Chi Gong, etc? ______</p><p>Thai bodywork is done on a mat on the floor. It is a physical practice. Would you have challenges working on your knees or with any other sort of physical issue? If yes, please explain. </p><p>______</p><p>The program at Blue Lotus will challenge you physically, mentally, and emotionally. Do you feel like you have the level of maturity required to take on these sorts of challenges? In other words, are you here to just get a certificate so you can add Thai bodywork to your list of things you do, or are you here to really step in and explore your potential while at the same time, becoming aware of and challenging your habits? </p><p>______</p><p>Initials______www.bluelotusthai.com Page 3 Payment Options</p><p>Please check one of the $400 Deposit options below:</p><p>____Enclosed is a check. (made out to Blue Lotus Thai Healing Studies and sent to: PO Box 6046 Lindenhurst, IL 60046)</p><p>____I am paying by credit card. Please use the information on this application to process my card.</p><p>Please check one of the Program Tuition options below: </p><p>1. Early Registration (Full payment or deposit received one month prior to program start date)</p><p>_____ Pay Entire Amount in Advance: $2600 </p><p>_____ Payment Plan: $2800 (6 monthly installments of $400)</p><p>2. Regular Registration (Full payment or deposit received within one month of program start date)</p><p>_____ Pay Entire Amount in Advance: $2900 </p><p>_____ Payment Plan: $3100 (6 monthly installments of $450)</p><p>3. If you are receiving a discount, please note it below(ie. you came to one of the information meetings, etc)</p><p>Discount amount ______</p><p>Please check one of the payment options below:</p><p>____I am allowing Blue Lotus to process my credit card on file, on the first day of each weekend class/supervised practice.</p><p>____I would like to pay by check or cash each month. I will hand it in on the first day of each weekend class/supervised practice. I understand my credit card information is to be kept on file even if it will never be used.</p><p>____ I would like to leave my options open at this time. When paying by cash or check, I will hand it in on the first day of each weekend class/supervised practice. If using credit card, I will email [email protected] before the weekend class/supervised practice, to allow Blue Lotus to process the card.</p><p>If any of your financial information changes during the program (such as new credit cards or you decide to pay with a check after paying with credit), please contact the Office Manager, Nancy Hamel, at [email protected].</p><p>Initials______www.bluelotusthai.com Page 4 Payment Information</p><p>PAYMENTS can be made by credit card, cash or check. </p><p>CREDIT CARD INFORMATION is required for our files regardless of the payment method.</p><p>DEPOSIT of $400 is required with this application. It guarantees your space in the class. The deposit is a portion of the tuition.</p><p>TUITION is the total program cost that will be paid to Blue Lotus by the end of the program. These are the prices shown on page 4 of this application. The tuition price includes the deposit. The price of tuition is contingent on the registration status (Early/Regular) and payment plan (Pay in Advance/Payment Plan). Insurance, books, mats, sheets, parking, monthly required professional Thai bodywork sessions and other potential or unforeseen costs are not included in the tuition price.</p><p>EARLY REGISTRATION deadline is one month prior to the first day of class.. The application and deposit payment must be received before the early registration deadline in order to get the early registration price. </p><p>REGULAR REGISTRATION price goes into effect when the application and deposit payment are received after the early registration deadline and before the first day of class. </p><p>PAY IN ADVANCE means that the entire tuition is to be paid in full.</p><p>PAYMENT PLAN - After the deposit is paid, the remainder is to be paid in 6 monthly installments, due on the first day of each weekend class for the Six Month Program. This is a payment plan for the entire program. It is not a payment for each individual weekend class. Missed Classes</p><p>* Student is responsible for the payment of all missed classes. If on a Monthly Payment Plan, the payment is still expected on the first day of the weekend, whether it is attended or not. If you paid in advance, there are no refunds for missed classes. * In order to graduate, missed classes may be made up by individual sessions as coordinated with the Director for an additional fee. Refund Policy</p><p>Cancellation is to be submitted to the director of the school in writing, by email or otherwise. If the cancellation is made: * before midnight of the fifth business day after the student has been admitted, and before the program begins (Sept. 18th) - the student has the right to cancel with a full refund granted. The deposit plus any tuition paid will be refunded. * after the fifth business day after the student has been admitted and before the program begins (Sept 18th): - $250 of the deposit will be refunded. $150 of the deposit will not be refunded. - all tuition paid will be refunded. * before the beginning of the second day of the program (September 19th): - $100 of the deposit will be refunded. $300 of the deposit will not be refunded. - all tuition paid, in addition to the deposit, will be refunded. * after the first day of class attendance of the program (between the Friday of the September weekend and prior to the program completion): - the whole $400 deposit will not be refunded. - the student is responsible for payment of all weekends up to the point where a cancelation notice is submitted. - if a cancelation notice is submitted within a weekend where there had been attendance, the student is still responsible for the payment of that weekend.</p><p>If tuition is paid in full before the program begins, all of the above applies, with tuition refund based on the timing of the </p><p>Initials______www.bluelotusthai.com Page 5 cancellation and on the pricing of the applicable program (early/regular, 6/12 month). </p><p>If a student withdraws from a program and decides to join a future program, there is a $200 class transfer fee.</p><p>Statements of Understanding About the Thai Massage Program at Blue Lotus</p><p>____ I acknowledge that I understand that this program is not a massage license program. Blue Lotus does not have accreditation by any agency which is acknowledged by the State of Illinois, or any other state, which would allow licensing by a state board.</p><p>____I acknowledge that I understand that if I am not a Licensed Massage Therapist (LMT), I cannot use the word “massage” to describe the work that I will do. Thai Yoga Therapist, Thai Bodyworker, and Thai Therapist are all used in the field. </p><p>____I acknowledge that I may be self-employed in my chosen field and that Blue Lotus does not guarantee a job or clients to any graduates. </p><p>____ I acknowledge that I will receive or have received at least one Thai massage before starting this program.</p><p>____ I agree to treat myself and others in the classroom with respect and compassion. I will work together with students and teachers to create and preserve a healthy and supportive learning environment. </p><p>___I agree with the terms of the payment policies as stated in this application.</p><p>___I agree with the terms of the refund policy above.</p><p>I certify that I have read and understand the previous Statements of Understanding and I declare that all information provided on this application is true to the best of my knowledge.</p><p>Signature______Date______</p><p>Credit Card Information</p><p>Your credit card number is required to be on file regardless of your method of payment. You may provide your information below or to the Blue Lotus representative during your phone interview:</p><p>Card Number (Visa or MC Only)______</p><p>Expiration Date ______3 digit Security Code on the back of the card______</p><p>Upon reviewing this application, someone at Blue Lotus will contact you for a phone interview. If, after the phone interview, it is determined that we are a good match, your payment will be processed and you will receive a welcome letter admitting you into the program. Initials______www.bluelotusthai.com Page 6 Initials______www.bluelotusthai.com Page 7</p>