Apply Now Lakewood School - Application for Admission Full Name: Email Phone #: ( ) - Birthdate Address Street Address Address continued City StatePlease select... Please select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip Education High School Diploma or GED City and State Year of Graduation Education College/Advance Education City and State Year of Graduation Medical Information Please select any of the following that pertain to you:Contact LensesDiabetesFrequent HeadacheDenturesHigh Blood PressureHeart ProblemsPregnancyChronic Back PainBlood ClotsMuscle SpasmsArthritisOsteoporosisDigestive ProblemsTumors or CystsAcute InjuryAneurysmsInfectious Diseases Please explain selected items Is ongoing medical supervision required?Please select... Yes No Currently taking medication?Please select... Yes No Please list Emergency Name Emergency Phone How did you learn about Lakewood School? Have you received a one-hour professional massage?Please select... Yes No Date / Name of Therapist Have you ever been convicted of a felony?Please select... Yes No Program Selection Please select your program choice:Please select... Fall Program (August-June): Tuesday Day Class Program (August-June): Monday/Thursday Evening Class Winter Program (February-December): Thusday Day Class I hereby state that all of the above information is true to the best of my knowledgeCheck Need assistance with this form?