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MCKS Pranic Healing Level 1 Course
Student Registration Form
Instructor: Brittany Smith / Marianne Chung
Location: Washington, DC
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Which class would you like to enroll in?
Choose
Oct 5-6
OCT 26-27
Nov 5-6 (in Spanish)
NOV 16-17
Dec 7-8 (in Mongolian)
Name
*
PRINT NAME as you want it to appear on the certificate
Your answer
Address
*
Add street address, city, state and zip code
Your answer
Telephone
*
Your answer
Email
*
Your answer
Occupation
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
How did you hear about Pranic Healing?
*
Your answer
Referred by
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Please check the appropriate box
*
Early Bird Basic Pranic Healing (2 weeks prior) $375
Basic Pranic Healing Course $400
Basic Pranic Healing (At Door) $425
Review Fee $100
Other:
Required
If you are reviewing the course, please list the date and place your Basic PH class was taken and name of instructor.
Your answer
For your safety, please answer the following questions:
*
Yes
Rarely
No
Do you smoke?
Do you take drugs?
Do you drink alcoholic beverages?
Yes
Rarely
No
Do you smoke?
Do you take drugs?
Do you drink alcoholic beverages?
What is your diet?
*
Vegetarian
Non-Vegetarian
Have you been diagnosed or had history of contagious diseases or other illnesses?
*
Yes
Undiagnosed
No
If you checked yes or undiagnosed, please specify.
Your answer
Thank you for your registration! We look forward to seeing you at the event.
If you have any questions, please email
twinheartsdc@gmail.com
.
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