Apply Now Lakewood School - Application for Admission Full Name: Email: Phone #: ( ) Birthdate Medical Information Please select any of the following that pertain to you: Contact Lenses Diabetes Frequent Headache Dentures High Blood Pressure Heart Problems Pregnancy Chronic Back Pain Blood Clots Muscle Spasms Arthritis Osteoporosis Digestive Problems Tumors or Cysts Acute Injury Aneurysms Infectious 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?