Personal Training

Chair Massage

Be part of our team ~

Thank you for your interest in working with Jiva. We are looking for motivated and educated individuals who bring passion and knowledge to their work helping others on their journey to wellbeing. Our service helps to facilitate business between Trainers/Therapists and those who desire your services. Our team consists of those who like to work independently but realize it can be a struggle to constantly keep growth in clientele. We take care of the marketing and sales allowing you more time to actually work with the client. Whether you want a few part time clients or if your looking for a lot of growth, Jiva can be your partner in assisting you to that level.

Please take the time to complete the following form and press submit. Along with your form please provide the following to us by U.S. mail, Fax, or Email. (Jiva 63 Waterbury Road Warwick, NY 10990 or info@jivawellness.com)

1). Personal Training Certification or Massage License(s) or Permits
2). Professional Liability Insurance
3). Driver's License
4). Professional Photo of yourself

Once all your documents are received, a Jiva representative will be in touch with you to finalize your request to become an Independent Contractor to Jiva. Upon approval of your submission you will be required to add Jiva as additional insured to your professional liability insurance. We look forward to hearing from you!


First Name
Last Name
How did you hear about us?
Date of Birth   (mm/dd/yy)
SSN
Address
City
State
ZIP Code
County
Home Phone
Cell Phone
Email
Driver's License #
Driver's License State
Do you have reliable transportation?   Yes       No
Do you have Professional Liability Insurance?   Yes       No
Liability Insurance Provider
Liability Insurance Expiration Date
Are you currently employed?   Yes       No
Please provide a detailed list of all surrounding cities and areas you are willing to service. (Please be very specific, as these will be key search terms for web browsers to find your web page that will be developed through Jiva).

How long have you been working as a massage therapist or personal trainer?
Do you currently have your own business?   Yes       No
Date available to begin providing services for Jiva clients   (mm/dd/yy)
If you currently have any valid Personal Training Certification or Massage Therapy License(s) or Permit(s), please provide the following information:
Name State or Location Expiration Date License/Certificate #
Have you been convicted of a crime in the last ten (10) years?   Yes       No
If so, please explain:

Next 3 Questions for Personal Trainers Only
List any fitness equipment you own
Have you ever done In Home Personal Training Before?
Please list your specialties
Next 3 Questions for Massage Therapists Only
Do you own your own massage chair?
What kind is it?
Please list your specialties
Please indicate your general hours of availability

  Start End
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please provide your employment information for the past 5 years.
Company Name
Phone
City
State
Start Date
End Date
Reason for Leaving
Company Name
Phone
City
State
Start Date
End Date
Reason for Leaving
Company Name
Phone
City
State
Start Date
End Date
Reason for Leaving
May we contact your previous employer for references?   Yes       No
Please list 3 Client references:
Name Phone
Emergency Contact (not living with you)
Emergency Contact Name
Emergency Contact Phone
Please provide an accurate description of what makes you an excellent trainer or therapist. We may include this information on our directory of trainers & therapists so use this space to get the clients attention so they would like to book their services with you.

Please cut and paste your resume in the box below

Therapist acknowledges that submission of this Request to Provide Services is as an independent contractor only. This is not an application for employment and therapist/trainer is not seeking employment with Jiva. By signing below I acknowledge that all the information I have provided is true and correct.