massage therapist school by mrshields

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									                           New Mexico Regulation and Licensing Department
                                          BOARDS AND COMMISSIONS DIVISION
                                                Massage Therapy Board
                               T on ey An a ya Bu i ld in g ▪ 2550 Cerr i llos Ro ad ▪ Sa nt a Fe, N ew Mex ico 87505
                                   ( 505) 476 -4870 ▪ Fax (505) 476 -4645 ▪ www.r ld .st at e.nm.u s/m as sa ge


            MASSAGE THERAPY SCHOOL 2008 RENEWAL APPLICATION
                              Your school registration renewal is due on October 31, 2008.

                                                          INSTRUCTIONS
          This renewal application must be legibly printed in black ink or filled in using your computer. To fill in
           the fields using your word processor, enter information in the gray boxes and tab to move from field
           to field.
          This renewal application must be completed in its entirety and accompanied by all supporting
           documentation before it will be sent to the Board for approval. Incomplete renewal applications will
           be returned for completion.
          It is your responsibility to ensure that the completed application is returned to the Board office before
           the deadline, October 31, 2008.
          This completed applications, required documentation, and fees must be postmarked or hand-
           delivered to the Board office on or before the renewal date to avoid incurring a late penalty fee.
          Complete renewal applications post-marked or hand-delivered after the renewal date, and prior to
           December 30, 2008, must be submitted with the renewal fee, plus the late penalty fee listed above.
          Registrations not renewed on or before the grace period ending December 30, 2008, will be
           automatically placed on EXPIRED status without further notification from the Board.
          Registrants who desire to renew an EXPIRED registration must make application to the Board and
           comply with the same requirements as any previously unregistered applicant.
          Schools with a non-renewed registration may not operate either during the grace period or after
           (Section 12 of Part 12 16.7.12 NMAC).


 Grace Period Ends: 12/31/2008                                                          Renewal Fee:                         $    50.00
 License Number:                                                                        Late Renewal Penalty Fee:            $    75.00

    SECTION A - SCHOOL INFORMATION
NAME OF SCHOOL


MAILING ADDRESS


PHYSICAL ADDRESS - - No. & Street



CITY                                                                 STATE                                   ZIP CODE
NAME OF SCHOOL DIRECTOR                                              CONTACT PERSON


PHONE                            E-MAIL                                                  WEBSITE



    SECTION B – CURRICULUM
The information outlined in the following section is to be provided for programs offered for the period of November 1 of the current year to
October 31st of the following year. The outline for the entire curriculum is required in this Section. The curriculum for each program must
be no less than 650 hours. The information outlined and requested in this Section is to be provided for EACH program offered, including
day, evening, and weekend program. Therefore, this Section may be copied for each program to be offered. Each program must have a
separate calendar. You may offer more courses and hours than the requirements outlined in the Massage Therapy Practice Act and its
rules, but NOT LESS. The program CANNOT include continuing education training, life experience, experience gained through
employment related to the program, or training provided by a Visiting Massage Therapy Instructor. Note: Hours MUST be specified for
EACH item listed in this Section that your school provides instruction in its curriculum.




                                                           Revision date: 09/2008
                                         Massage Therapy Board
                           MASSAGE THERAPY SCHOOL 2008 RENEWAL APPLICATION

         SECTION B – CURRICULUM – Program No.:                     of
                                          Hours:                                                              Hours:
ANATOMY & PHYSIOLOGY (Min. 165 hours.):   Theory   Practice   GENERAL INSTRUCTION (Min. 75 hours.):           Theory     Practice
 Anatomy                                                       Hydrotherapy
 Physiology                                                    Business
 Kinesiology                                                   Professional Ethics (to include 16.7.2 NMAC)
 Pathology                                                     First Aid
 Other (List):                                                 Cardio Pulmonary Resuscitation (CPR)
                                                                Other (List):




Sub Total:                                                     Sub Total:
Theory & Practice Total:                                      Theory & Practice Total:

                                          Hours:                                                               Hours:
MASSAGE THERAPY (Min. 150 hours):         Theory   Practice    ELECTIVES:                                     Theory     Practice
Massage Therapy (Min. 150 hours)                               Related Hands-on Modalities (List):
Contraindications of Massage Therapy
Other (List):




 Clinical Practicum (Max. 150 hours)      N/A
Sub Total:                                                    Counseling
Theory & Practice Total:                                      Herbology
                                                              Homeopathy
                                                              Nutrition
CURRICULUM TOTAL (Min. 650 hrs.):                             Breathing & Stretching Techniques
                                                              Theory
                                                              Other (List):




                                                              Sub Total:
                                                              Theory & Practice Total:




                               New Mexico Regulation and Licensing Department
                                   BOARDS AND COMMISSION DIVISION
              Page 2 of 6                                                                       Revision date: 09/2008
                                          Massage Therapy Board
                            MASSAGE THERAPY SCHOOL 2008 RENEWAL APPLICATION

           SECTION C – SYLLABI
    The syllabus must be provided for the entire curriculum.
    The calendar for each program need NOT be submitted. However, the calendar for each program must be in place no later than the first day of
     class. Furthermore, the Board and/or its designee may conduct an audit of the calendar with or without prior notification or arrangements.
 The information outlined in this Section is to be provided for ALL curriculum outlined in Section B. However, if the course is offered in more
     than one program, the syllabi for the course only needs to be provided ONE time.
 EACH course must be broken down with a separate page(s) for each course, and grouped in the order outlined in Section B. (e.g. All elective
     courses for all programs must be grouped under “Electives”, with the tabs/dividers separating the category, i.e. A&P, MT, General, and
     Electives.
 All boxes must be checked, and all boxes checked must have the supporting documentation/information requested attached/enclosed.
The following minimum information must be provided for each course:
                Name of course (exactly as outlined in Section C of this application)
                Detailed description
                Objectives
                Required school prerequisites
                Where applicable, required Massage Therapy Board prerequisites
                Total number of class or contact hours required (exactly as outlined in Section C of this application) to
                include the definition outlined in 16.7.1.7.B NMAC
                Name of instructor(s), where applicable include the registration number of the Massage Therapy Instructor.
                Instructors who are registered as Massage Therapy Instructors must be listed with the name as inscribed
                on their registration
                Instructional materials to be used
                Provisions for make-up work, if any
                Requirement for successful completion
                Revision date.

           SECTION D – REQUIRED DOCUMENTATION
Although the Board is not requiring you to submit the supporting documentation listed in this section, the Board and/or its designee may conduct an audit of the
documentation with or without prior notification or arrangements.
The following minimum requirements MUST be met and in place at the time of renewal. ALL boxes MUST be checked attesting that the requirements have
been met and documentation is in place.
ADMISSION APPLICATION
            Full name of the applicant, to include address phone number and date of birth;
            If applicable, Application Fee, and terms relating to cancellation and refund; and
            A certification statement certified and dated by the applicant, certifying that the applicant has received a complete copy of the
            Admission Application and any attachments referenced to in the admission application and admission supplements.
ENROLLMENT AGREEMENT/CONTRACT: the enrollment agreement/contract is in place and it includes at a minimum the information
listed below:
            School name, address and phone number
            Total tuition cost for the program
            Tuition cost for partial training per hour
            Enrollment Fee including tax
            Minimum tuition deposit required
            Cost for books, supplies and other expenses
            Administrative costs for withdrawal or termination
            Payment methods and terms including interest
            Refund policy
            Right to cancel enrollment agreement (school and student)
            Right of withdrawal or termination of enrollment (school and student)
            Withdrawal or termination prior to start of program
            Withdrawal, abandonment or termination after program starts
            Program start date
            Credits, hours and financial, for prior training
            Total hours of program, including prior training credit
            Attendance requirements
            Attendance requirements

                                   New Mexico Regulation and Licensing Department
                                       BOARDS AND COMMISSION DIVISION
                Page 3 of 6                                                                                                 Revision date: 09/2008
                                       Massage Therapy Board
                         MASSAGE THERAPY SCHOOL 2008 RENEWAL APPLICATION

          Employment disclaimer;
          Graduation requirements;
          A certification statement certified and dated by the applicant, certifying that the applicant has received: (1) a complete copy of the
          Enrollment Agreement/Contract and any attachments referenced to in the enrollment agreement/contract and enrollment
          agreement/contract supplements; (2) the calendar for the enrolled program or the date when the calendar for the enrolled program
          will be provided, which shall be provided no later than the first day of class; and (3) the advertising catalog, and catalog supplements
          outlined in Attachment 5 of this application.

ADVERTISING CATALOG: The advertising catalog is in place and it includes at a minimum the information listed below:
            Date catalog and catalog supplement was printed/revised
            School name, address (mailing and physical), telephone number, e-mail address and website
            Table of contents and page numbers
            Mission, objectives, and goals of the school
            List of facility with their titles, which may include instructors and where applicable their Massage Therapy Instructor registration
            number
            Admission requirements, procedures and prerequisites
            Grading system
            Length of time required for completion of the program
            Completion, graduation requirements
            Attendance Policy
            Leave of Absence Policy
            Dress Code Policy
            Sanitation/Hygiene Protocol Policy (personal hygiene, washing of hands after a massage treatment, cleaning lotion bottle,
            cleaning table, linen care, equipment care, etc.)
            Universal Precautions Policy
            Draping Policy and Procedures
            Student Complaint Policy – to include the Massage Therapy Board name, address (mailing and physical), telephone number, e-
            mail address and website, as an avenue to file a complaint, only after the student has exhausted the procedures available at the
            school, or if extreme circumstances exist whereby the student cannot utilize the school’s procedures.
            Student Conduct and Ethical Requirements – to include outlining 16.7.2 NMAC in the ethical requirements, and including outlining
            the basis for termination and the termination procedures.
            Transfer Credit Policy – which provides the process and verification procedures to be followed when accepting training received by
            the student from another school, and how the transfer courses will be reflected on the transcript. Such training transferred
            CANNOT include continuing education, life experience or experience gained through employment related to the program of study.
            Courses transferred shall parallel in content and intensity to the courses presently offered by the massage therapy school.
            Partial Training Policy – which provides the process used for students who completed their training in another school and lack the
            minimum educational requirements for licensure. The course(s) and hours for partial training shall correspond to the course(s)
            and hours outlined in Section C of this application.
            Readmission Policy – which provides the process and timelines in which a student who has withdrawn from the school’s program
            can reapply and obtain credit for the training completed at the school, before the student must complete the entire program and no
            credit for past training completed will be credited.
                                                                 Clinical Practicum Policies and Procedures – to include at a minimum the following:
                   Massage Therapy Board exemption provision outlined in the Massage Therapy Practice Act, 61-12C-5.1.B
                   Massage Therapy Board “Clinical Practicum” definition (16.7.1.7.C NMAC)
                   Massage Therapy Board “Professional Conduct” rule (16.7.2 NMAC)
                   Massage Therapy Board “prerequisite” requirement outlined in 16.7.5.8.B (2)(b) NMAC
                   Massage Therapy Board “Students” rule (16.7.7 NMAC)
            Disclosures, to include at a minimum the following:
                   Massage Therapy Board age requirement in order to obtain a massage therapy license (16.7.4.8.A (1) NMAC)
                   Massage Therapy Board high school or its equivalent requirement in order to obtain a massage therapy license (16.7.4.8.A
                   (2) NMAC)
                   Massage Therapy Practice Act requirement that persons must be licensed as Massage Therapists in order to advertise and
                   offer massage therapy services
    Licensure Requirements – a brief description of the Massage Therapy Board requirements, to include at a minimum the following:
          Licensure minimum educational requirements
          Examination requirements including the National Certification Examination for Therapeutic Massage and Bodywork and the State
          Jurisprudence Examination
                               New Mexico Regulation and Licensing Department
                                   BOARDS AND COMMISSION DIVISION
              Page 4 of 6                                                                                         Revision date: 09/2008
                                        Massage Therapy Board
                          MASSAGE THERAPY SCHOOL 2008 RENEWAL APPLICATION

           Advertising requirements including the requirement that licensure for the practice of massage therapy is required in the Massage
           Therapy Practice Act in order to offer and/or advertise massage therapy services
           Massage Therapy Board address (mailing and physical), telephone number, e-mail address and website for obtaining information
           and the application packet needed to apply for licensure
   Student Complaint Policy & Procedures, to include the Massage Therapy Board name, address (mailing and physical), telephone number,
   e-mail address and website, as an avenue to file a complaint, only after the student has exhausted the procedures available at the school,
   or if extreme circumstances exist whereby the student cannot utilize the school’s procedures; which is required to be posted in a
   conspicuous place on the premises
TEACH-OUT POLICY: The teach-out policy is in place and it includes at a minimum the information listed below:
   The name of at least one (1) registered Massage Therapy School (“receiving school”) with which a teach-out agreement has been entered
   into, the agreements shall include that the receiving school shall receive at a minimum the following:
           A current and past listing of all students, including their date of birth.
           Current and past student records, which must include an original transcript of the courses, hours, dates, and instructors names for
           the courses taught by each instructor and completed by the student.
           Proof of paid and unpaid tuition, refunds due, and account balances.
           The method and timelines to be used to ensure the receiving school receives any amounts due, or the students are refunded any
           amounts due.
   If there is no teach-out plan with a registered massage therapy school, then the teach-out plan must include providing the massage
   therapy board with the following:
           A listing of all students (current and past) with their date of birth.
           Student records (current and past), which must include an original transcript of the courses, hours, dates, and instructors names for
           the courses taught by each instructor and completed by the student.
           Proof of paid and unpaid tuition, refunds due and account balances.
           The method and timelines to be used to ensure the students are refunded any amounts due.
   The teach-out plan must also include the procedures and timelines the school will follow prior to the school closing in providing notification
   to the students, the receiving school, and the massage therapy board of the impending closure and the timelines for issuance of refunds,
   and transferring all student records (current and past) to the receiving school or the massage therapy board
FORMS: At a minimum, the following forms are in place:
   Instructor evaluation of the student on massage therapy techniques.
   Student evaluation of the instructor on the teaching provided.
   Client intake and screening, which is used to obtain relevant information from the client.
   Disclosure statement, which includes prior informed consent regarding draping and treatment, privacy of the client while dressing and
   undressing, modification or termination of treatment at the client’s request, maintenance of equipment, linens, clothing and work area, etc.
   Client feedback, which is used to evaluate the student on the services rendered.
TRANSCRIPT: To include at a minimum, the following:
   Full name of school, as registered with the Massage Therapy Board, to include mailing address, phone number, fax number,
   e-mail address and website.
   Signature of school director, to include date of signature.
     The heading entitled “Official Transcript” or equivalent.
     School seal affixed to the transcript.
     Full legal name of the student with the student’s date of birth.
     Date of entrance into the program.
     Date of completion of the program.
     The total hours that the student successfully received for the program.
     The course name, number of hours successfully completed and the respective category credited (A&P, MT, General Instruction, or
     Elective) exactly as outlined in the curriculum in Section C.
     If applicable, for each course transferred from another school: (1) the course(s) name; (2) number of hours transferred for each course;
     and (3) the name of the transferring school(s); which shall have a copy of the transcript from the transferring school attached to the
     transcript.




                                 New Mexico Regulation and Licensing Department
                                     BOARDS AND COMMISSION DIVISION
               Page 5 of 6                                                                                       Revision date: 09/2008
                                                Massage Therapy Board
                                  MASSAGE THERAPY SCHOOL 2008 RENEWAL APPLICATION

 FACILITY AND INTSTRUCTORS: To include at a minimum, the following:
      Name, and where applicable, Massage Therapy Instructor registration number
           Course(s) that will be taught
           Documentation of the training and experience in the area of the course(s) that will be taught
           Resume
       Facility and Instructors Conduct and Ethical Requirements, including outlining the basis for termination and the termination procedures
 CLIENT CLINICAL PRACTICUM COMPLAINT POLICY AND PROCEDURES: To include the following information which must be posted in a
 conspicuous place on the school premises for the client to file a complaint of alleged violations of the Massage Therapy Practice Act or its
 regulations.
       The Massage Therapy Board’s name.
           The Massage Therapy Board’s address (mailing and physical)
           The Massage Therapy Board’s telephone and fax numbers.
           The Massage Therapy Board’s E-mail and Website addresses.
           The Massage Therapy Board’s telephone and fax numbers.
 FLOOR PLAN: To include all dimensions. The use of each room or space must be clearly labeled.
              SECTION E – THE FOLLOWING QUESTIONS MUST BE ANSWERED
 1. Within the last two (2) years, has the director, any board member or any person holding an ownership                                       Yes           No
 or controlling interest in this school been convicted of any offense punishable by incarceration in a state
 penitentiary or federal prison?
 2. Within the last two (2) years, has the director, any board member or any person holding an ownership or                                    Yes           No
 controlling interest in this school been involved in any civil litigation involving the operation, management,
 or practice of massage therapy?
 3. Is the director, any board member or any person holding an ownership or controlling interest in this                                       Yes           No       N/A
 school currently more than thirty (30) days in arrears in payment of amounts required to be paid pursuant
 to a court-ordered judgment and order.
 For any “YES” answer(s), you must provide details, including the outcome, on a separate sheet and attach supporting documentation including, but
 not limited to the following:
             Certified copies of the legal documents, certified by the Clerk of the court entering the conviction.
             Character reference letters from family, friends, colleagues, employer, etc., to include their addresses and phone numbers.
             If you are still on probation, an original letter addressed, signed, and submitted to the Board by your Probation Officer, which outlines
              the status of your probation and which is dated within one (1) month of the date of this application.
             For Question #3, a certified Statement of Compliance from Human Services Department (HSD) Child Support Enforcement Division
              (CSED), with a copy of the Judgment and Order for support; and any other relevant documentation regarding the matter.
                 SECTION F– APPLICANT’S ATTESTATION
I hereby certify that ALL instructors teaching “Massage Therapy” as defined in Sections 61-12C-3.E of the practice Act, and Section 16.7.1.7E
NMAC of the Board’s Regulations, are licensed as massage therapists and registered as massage therapy instructors by the Board. Under
penalties of perjury, I/we declare and affirm that the statements made in the foregoing application, including any attached documentation, are
true, complete, and correct. /we understand that any false or misleading information in, or in connection with, this application may be cause for
denial or loss of this school’s registration.
SOLE PROPRIETORSHIP OR OTHER:SIGNATURE: _____________________________________                                                                      DATE:   ___/___/____
PARTNERSHIP:
        SIGNATURE – PARTNER #1 ________________________________________________                                                                    DATE: ___/___/____
             SIGNATURE - PARTNER #2            ________________________________________________                                                    DATE: ___/___/____
             SIGNATURE - PARTNER #3            ________________________________________________                                                    DATE: ___/___/____
If there are more than three partners, make a copy of this page, complete this section on that sheet and attach it to the application)
PROPRIETARY CORPORATION OR LIMITED LIABILITY COMPANY:                                                                                              DATE:   ___/___/____
 CORPORATE OFFICER OR CORPORATE DIRECTOR OR OWNER: ___________________________________________________
PUBLIC INSTITUTION OR NON-PROFIT CORPORATION:                                                                                                      DATE:   ___/___/____
  AUTHORIZED GOVERNING BOARD MEMBER: _____________________________________________________________________

SCHOOL DIRECTOR: _____________________________________________________________________________                                                     DATE: _____/____/______


                                          New Mexico Regulation and Licensing Department
                                              BOARDS AND COMMISSION DIVISION
                    Page 6 of 6                                                                                                          Revision date: 09/2008

								
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