Printable Registration Form

I do not take credit or blame for any healing.  I do not diagnose conditions, nor do I prescribe or perform medical treatments, nor interfere with licensed medical professionals.

Continuing Education credits are available for all classes. (Approved by the CA Board of Registered Nursing - BRN #13837)

www.reikimastertherese.com

TjEnergy11@gmail.com

Reiki I, II and III with Reiki Master Therese Silva Johnson Class Registration Form and Continuing Education (CE) Course Registration Please Print

1. Social Security Number:______________________________________________________

2. Name____________________________________________________________________ Last First middle initial

3. Address___________________________________________________________________

4. Day Phone_________________________ Evening Phone__________________________

5. Birthdate_________________________________

6. Sex: Male___ Female___

Course Information

1. Today’s Date:__________________________ 2. Course Date ________________________ 3. Name of Course________________________ 4. Number of Contact Hours_________________ 5. Continuing Education: RN ___ LVN___ CNA___ CMT___ License No._____________ Residence Information

1. Have you taken courses through ARP before? Yes___ No___ If “Yes” date?______________ 2. Are you a U.S citizen? Yes___ No___ 3. Was your License issued in the United States? Yes___ No___ 4. Do you have a baccalaureate or higher degree? Yes___ No___

5. I hereby certify under penalty of perjury that the above information is true and correct.

Student Signature__________________________________________________________________________Date_________________

INSTRUCTOR USE ONLY

Number of hours of instruction? ____Completed____Incomplete______

Date(s) of class session(s): M T W TH F S Final Grade = ___Pass___Fail

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Instructor's Signature___________________________________________________________________Date ____________________ 

Reiki Master Therese

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