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PRANIC HEALING LEVEL I WORKSHOP
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STUDENT REGISTRATION FORM
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Course Date:
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Name (as you want it to appear on your Pranic Healing Certificate):
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Gender
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Date of Birth:
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Address:
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City:
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State:
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Zip Code:
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Email Address:
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Contact Phone Number:
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How did you hear about Pranic Healing?
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Referred by:
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New Student Registration Fee
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Review Student Registration Fee
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For reviewing students, provide location, date, and name of instructor of initial Pranic Healing Level I Workshop.
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Pranic Healing graduates are eligible for a $25 referral fee for each new student who completes the Level I Workshop.
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Name of Student(s):
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CONFIDENTIAL STUDENT DATA
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Do you smoke?
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Do you take drugs?
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Do you drink alcoholic beverages?
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What is your diet?
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Have you been diagnosed or had a history of contagious diseases or other illnesses?
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If yes, please specify
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Do you have a history of present serious physical or psychological disorders?
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If yes, please specify
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Do you have any heart problems?
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Do you have high blood pressure?
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Are you pregnant?
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Will you be earning General CEU Hours?
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License #
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WAIVER: I promise that I will not give, teach, or divulge the techniques and teachings derived from the workshops to anyone without Master Choa Kok Sui's approval. I also promise not to misuse the knowledge that I derived from the workshops. I acknowledge that the courses developed by Master Choa Kok Sui are copyrighted and are not to be reproduced in any way without his approval.
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Consent
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Date:
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Payment Options:
Cash
Check
Credit Card--Call in Information to 386.747.5800
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Check Amount:
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Check Number:
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Check Date:
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Mail payment to SouthEast Regional Pranic Healing Centre, 210 New Edition Court, Cary, NC 27511. Make checks payable to SERPHC.
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