Reiki Certification Application

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Name:

Email:*

Re-enter Email:*

Please indicate street address, city, state and zip.

Address*

Home Phone:*

Cell Phone*

Occupation/Vocation*

Date of Birth

How long have you been interested in Reiki? Why?

Reiki Interest*

Please name your background, if any in Reiki

Reiki Background*

What is your current involvement with Reiki?

Current Involvement*

What does Reiki mean to you, and how has it affected your life?

What Does Reiki Mean to You?*

What are your expectations of this training and how will you utilize your certification?

Expectations*

Are you certified in other areas?

Other Certifications*

How did you hear about us?*

HEALTH INFORMATION FORM & WAIVER

Are you currently under medical treatment or supervision? If yes, please describe.

Current Medical Treatment*

Chronic Physical Limitations/Physical challenges (e.g. vision, hearing, movement, high blood pressure, asthma, etc.) Please describe the nature and extent of limitation(s) if any:

Chronic Limitations*

Serious illness or surgery within the last five years (e.g. heart, cancer, diabetes, etc.) Condition and date(s):

Serious Illness*

Any other surgery/procedures:

Other Surgeries*

Prescription Medications*

If yes, please describe.

Drug or Alcohol Addictions*

Are you currently pregnant?*

If yes, number of months at start of program?

Have you ever been hospitalized for anxiety/panic attack, emotional/mental condition? If yes, please describe.

Hospitalization*

Emergency Contact Name*

Emergency Contact Phone#*

Emergency Contact Relationship*

Emergency Contact Address*

Physician's Name*

Physician's Phone#*

DECLARATION OF DISCLOSURE & ACCEPTANCE OF TERMS

I hereby declare the above information is true to the best of my knowledge. I understand that misrepresentation of this information constitutes grounds for revocation of Certification.

I understand that I am entitled to no refunds, credits or adjustments resulting from my failure to complete the certification requirements or to uphold any of these conditions.

Please write your name to confirm your understanding of the Declaration of Disclosure and Acceptance of Terms.

Signature*

Today's Date*

Please use this area to provide any additional information, if necessary.

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