MCKS Pranic Healing 2020 Winter Course Registration
Student Registration Form
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Course Registration *
Please check all appropriate boxes.
Name *
Print name as you want to appear on the certificate
Address *
Add street address, city, state and zip code
Telephone *
Email *
Occupation *
Date of Birth *
How did you hear about Pranic Healing? *
Referred by
Please check the appropriate box *
If you are reviewing the course, please list the date and place your Basic Pranic Healing class was taken and name of instructor.
For your safety, please answer the following questions: *
Do you smoke?
Do you take drugs?
Do you drink alcoholic beverages?
What is your diet? *
Have you been diagnosed or had history of contagious diseases or other illnesses? *
If you checked yes or undiagnosed, please specify.
Thank you for your registration! We look forward to seeing you at the event.
If you have any questions, please email us at
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