REGISTRATION FORM RELEASE CONSENT

First Name

Last Name

8) PHONE NUMBERS:

7) EMAIL ADDRESS:

Reiki Tummo 1

Reiki Tummo 2

Reiki Tummo 3A

Meditation

Kundalini

New

Repeat

New

Repeat

New

Repeat

New

Repeat

New

Repeat

1) CITY:

2) DATE:

3) PARTICIPANT'S NAME:

4) BIRTHDATE:

5) NAME AND TITLE AS YOU WISH IT TO APPEAR ON CERTIFICATE:

CHECK IF SAME AS ABOVE; OR AS FOLLOWS:

6) MAILING ADDRESS: (Please compete with State/Province and Post/Zip Code)

STATE/PROVINCE AND POST/ZIP CODE:

9) OCCUPATION: (Please specify if Clergy, Full-time Student, Senior/Retired, Child, or your profession)

10) WORKSHOPS: (Check al that apply) If repeating, please provide date, place and teacher/master name of your pevious workshop/attunement)

11) PREVIOUS ENERGY WORK/TRAINING:

RELEASE CONSENT

I,

, understand and agree to the following while taking the above mentioned workshops:

The workshops, their procedures, and/or techniques, that are shown, used, discussed and/or demonstrated are for educational purposes only.

No part of these workshops is presented either directly or indirectly as a diagnosis or prescription for any health problem(s). People with health problems should continue to seek appropriate professional help with qualified members of the medical profession.

People using the text procedures and practices do so for educational purposes only. During the Workshop, I will not use, demonstrate, practice or promote any techniques, not given in the Padmacahaya workshops, as they may cause confusion or misunderstanding to other workshop participants.

Padmacahaya and the workshop coordinators will not be responsible for any such activity. I understand that my personal information will only be used for workshop registration purposes by Padmacahaya and will not be sold or
disclosed to any other parties.

Date:

Participant's Signature:
(please print, sign and mail it along the registration fee)