Integrative Reiki 1 & 2 Registration Form

Name as you would like it to appear on your certificate * *

Mailing Address *

Email Address *

Phone Number *

How did you hear about our Reiki Class?

Website
Social Media
Word of Mouth
Other

Comment or Question

Terms of Use *

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Yes, I want to submit this form & agree to the terms of use. *