Reiki Certification Courses                   Personal Info Inquiry & Liability Waiver
Please Complete the following information and click submit. Thank you kindly.
Sign in to Google to save your progress. Learn more
Name *
Please list your first and last name.
Nick-Name/ Preferred Name
If you have a preferred name, please type it here.
Phone number *
Email Address *
Please list your primary email address below.
Home/Mailing Address *
Please list your mailing address: Street, City, State, Zip Code.
Please Select the course in which you will be attending. *
Please select the date of your class. *
If more than 1 day, please select the date of Day 1.
Please list the first and last name that you would like to appear on your completion certificate. *
Please be sure to double check spelling
Social Media Handle: Instagram 
This is to be tagged by @Selfcareextraordinaires on Instagram
Would you like to receive correspondence about upcoming classes and workshops? *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Massage by Niccole, LLC. Report Abuse