Camp Pebble Wellness Institute 
Massage Therapy Certification Program Application
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Application for Admission -
Which session Start Date are you applying for?
 *
Full Legal Name *
Address (include City, State, Zip): *
Phone Number: *
Email: *
In case of emergency, contact: Name and Phone Number *
Emergency Contact - Relationship to you: *
Current Occupation: *
Current Occupation - Work Address: *
Education Background *
Did not complete
Yes
No
Does Not Apply
High School
Tech School or Vocational School
College
Other Professional Courses
High School attended (Please state your name on school records, if different)

School, City, State, Degree Achieved
Tech/Vocational School attended (Please state your name on school records, if different)

School, City, State, Degree Achieved
College attended (Please state your name on school records, if different)

School, City, State, Degree Achieved
Other Professional Courses attended (Please state your name on school records, if different)

School, City, State, Degree Achieved
Classes related in the health sciences (classes taken, number of classroom hours, date of completion)
Occupational Experience (please state your last 3 employers)

Job Title, Employer, Address, Employed to/from date
 *
Have you ever been convicted of a felony or misdemeanor *
If yes, please explain.
Health Background
Health Status (please check if you have any medical conditions or restrictions which affect your ability to: *
Required
If yes to any, please explain:
Do you have any allergies or any medical conditions (physical, mental or emotional) *
If yes, please explain:
Are you taking any prescription drugs that might interfere with your ability to complete this course?  *
Required
If yes, please explain:
Do you use recreational drugs or alcohol: *
Required
If yes, has that ever affected your ability to function in daily life?
If yes, please explain:
Are you currently under medical supervision? *
Required
Please explain if this will affect your ability to participate in this program:
Please describe any physical challenges you have which may influence your performance as a massage therapist: *
Please describe any learning challenges you have that could impact your success in this program: *
Please describe any mental or emotional challenges you have that could impact your success in this program: *
Massage and/or Health and Wellness Experience and Education. 
List and describe briefly.
 *
Supporting Documents
Supporting Documents
In addition to an admission interview, the following documents are part of your application. Application will be conditional until the supporting documents are received and approved.
  • Two letters of recommendation indicating your personal skills and characteristics that qualifies you for a profession in Massage Therapy. 
  • A $50.00 non-refundable application/interview fee.
  • Transcripts from your high school (or equivalent) or college transcripts with a minimum of 60 completed credits. (These transcripts must be mailed to Camp Pebble by the institution issuing them.)  
Send to: Camp Pebble Wellness Institute
                     229 East Sheridan Street
                        Ely, Minnesota 55731
 
Essay Question: Please type your response.

1. Tell us about yourself (interests, hobbies, attributes, etc.) *
Essay Question: Please type your response.

1. Tell us why you wish to become a professional massage therapist.
 *
Application Agreement

I certify that the information I have provided on this application is complete, accurate and true to the best of my knowledge. I understand it is my responsibility to request official transcripts from each academic institution that I have attended, and transcripts submitted directly to the Pebble Institute. I understand that any misrepresentation/omission of application information is sufficient grounds for canceling my admission and enrollment and is grounds for dismissal and releases Pebble Institute from any liability.

Any financial obligation that I have incurred will be my responsibility to pay in full. I understand that documents are not released until all financial obligations are met. By submitting this application, I agree to abide by and be subject to the Pebble Institutes rules, regulations and discipline.


Name and Date: *
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