<p> CHANDLER-GILBERT COMMUNITY COLLEGE THERAPEUTIC MASSAGE PROGRAM APPLICATION</p><p>Desired Start: Fall 20___</p><p>Name ______Last First Middle</p><p>Former or Maiden name(s) that may identify transcripts______</p><p>Student ID# ______Phone (______) ______- ______email______</p><p>Mailing Address </p><p>______Street City State Zip</p><p>Current Occupation/Employer ______</p><p>Have you worked in a Health Care setting before? Yes No </p><p>Have you completed (or will you by the fall semester) all 6 prerequisite classes? Yes No  BIO160  WED151  WED165  WED215  HCC130  HCC145AA</p><p>Check each level of education completed: GED High School Diploma AA Degree Other</p><p>Please specify any degree beyond high school</p><p>______</p><p>Therapeutic Massage Goal: Certificate of Completion (CCL) Associates Degree (AAS) </p><p>List name and location of each college attended College City and State Dates Attended</p><p>I certify that: 1. All information provided by me is true, correct, and complete. 2. It is my responsibility to provide all requested information to complete my file. Failure to provide all requested information may adversely affect my evaluation. 3. Admission into program is conditional until I have successfully completed all requirements. </p><p>______Applicant Signature Date</p><p>Therapeutic Massage (TM) Program Requirements</p><p>Acceptance into the Program</p><p>1. Meet all CGCC acceptance requirements 2. Meet with Program Coordinator 3. Complete all program prerequisite classes with a “C” or better grade 4. Submit this application form 5. Interview with the Program Committee – to be scheduled</p><p>Beginning the Program</p><p>1. Attend program cohort meeting after being accepted 2. Summer Paperwork – discussed at program cohort meeting  Immunizations  Health declaration from physician  TB skin Test  CPR for the Health Care Provider  Fingerprint card  Drug screening 4. Register for WED230 & WED231 (Program Coordinator signature required)</p><p>Please submit all paperwork to: Dr. Gregory A. Trone, Therapeutic Massage Program Coordinator</p><p>Office: CGCC Pecos Campus Estrella Hall #215 Phone: (480) 732-7289 Email: [email protected] </p><p>Chandler-Gilbert Community College, 2626 E. Pecos Rd., Chandler, AZ 85225 A Maricopa County Community College The Maricopa County Community College District (MCCCD) is an EEO/AA institution</p>