Reiki Certification Application

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Please indicate street address, city, state and zip.

How long have you been interested in Reiki? Why?

Please name your background, if any in Reiki

What is your current involvement with Reiki?

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

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

Are you certified in other areas?

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

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:

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

Any other surgery/procedures:

If yes, please describe.

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

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.

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