Name

Phone Number

Address

Date of Birth

Emergency Contact

Emergency Contact Phone Number

Allergies & Other Important Medical Info

Are you happy to share your contact information with class peers?

Please upload a clear photo of your lovely face ! [5MB max]

Student Photo

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Preferred Start Date:

October 18th 2019- May 21st 2020

October 2020 - May 2021

I want to attend but I need a different timing schedule.

Educational Information

I have graduated from high school or the equivalent.

I am fluent in English or am willing to hire a professional translator to assist me throughout the CMT program.

I have taken a Panacea course in the past

Personal References

Reference 1

Reference 1 Name:

Reference 1 Phone No.:

Relationship:

Reference 2

Reference 2:

Reference 2 Phone No.:

Relationship:

Have you ever been convicted of a felony?

Have you ever been convicted of a misdemeanor?

Were any of these convictions Expunged?

Disclaimer: In the state of California, a massage therapist is unable to obtain a license if s/he has been convicted of a felony. A misdemeanor may also preclude licensure.

WORK HISTORY

Please upload current resume

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FINANCIAL PLANNING

Are you planning to pay your tuitions in full?

Yes
$13,333 - Total Institutional Fees due upon Enrollment Registration
No
I would like to set up a tuition payment schedule. In which case I am comfortable to release estimated personal finance information to confirm eligibility

Payment via (check one)

Cash
Check
made payable and mailed to
Panacea Holistic Institute
2841 East Broadway
Long Beach, CA 90803
Credit Card
Request Square Invoicing
STUDENT RESPONSIBLE FOR CREDIT CARD FEES

Payment Plan options

3 part payment plan ($13,380 - Total Institutional Fees )
$4,460 due before the start of each trimester

(if CC is used - card kept on file)
(minus $ enroll. fee)

$555 enrollment fee ( EF)
(non refundable- due to reserve registration, EF is part of total tuitions due )
6 part payment plan ($13,428 - Total Institutional Fees )
$2,238 due before the start of each trimester & before the start of week 5 every trimester. (if CC is used - card kept on file)
(minus eroll. fee)

$555 enrollment fee ( EF)
(non refundable- due to reserve registration, EF is part of total tuitions due )
9 part payment plan ($13,400 total institutional fees)
$1,500 due monthly, payments 1-3 must be satisfied to start the program
(if CC is used - card kept on file)
(minus eroll. fee)

$555 enrollment fee ( EF)
(non refundable- due to reserve registration, EF is part of total tuitions due )

Student Eligibility Questionnaire

Individual Monthly Overhead

Individual Monthly Income

When do you have available time for your clinic and homework hours?

Are you considered a dependent by a spouse or parent?

Do you receive private/public benefits?

Financial Assistance Programs

Have you applied for Panacea Wellness Ambassador Scholarship?

Are you interested in partial work-trade?

Identity Verification

Please upload current Drive License or other Government ID

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Verification

I understand the above disclaimer and confirm that all of the above is true and correct.

I have read and agree to the terms above.

How did you hear about this course?

Application Fee :: $33

Application Fee

Coupon Code