Application for Usui/Holy Fire® III Reiki Practitioner Course Levels I & II

First name *

Last name *

Email (please double check for accuracy) *

Phone *

Is this a cell number *

Yes

Have you taken Reiki practitioner training before *

Yes

Have you ever been trained in any methods of hands-on healing or bodywork *

Yes

List all the modalities that you have practiced, past and/or present List all the modalities that you have practiced, past and/or present

Indicate the highest level of Reiki for which you were certified *

Level I

Level II

Master

What form or tradition of Reiki were you certified in What form or tradition of Reiki were you certified in

What year were you certified What year were you certified

How much have you practiced Reiki since your certification *

I practice Reiki regularly on myself and/or others

I practice Reiki off and on

I practice Reiki very little

I have not practiced Reiki in a very long time

I don't practice Reiki at all

Do you have proof of your certification *

Yes

Have you ever had a full Reiki session in person *

Yes

How familiar are you with Reiki healing *

Very familiar

Some but not much

Not familiar at all

How familiar are you with various alternative healing methods *

Very familiar

Some but not much

Not familiar at all

What is your purpose for taking Reiki practitioner training, check all that applies *

To become a professional Reiki healer

To become a professional Reiki healer and teacher

To complement my existing healing/medical profession

For self-healing

To heal family and/or friends

To heal animals

To learn more about Reiki healing method

Personal enrichment

Other, please describe Other, please describe

Do you have any special health conditions or needs that we should know about? If yes please explain, otherwise type "No" *

Do you have any spiritual or religious conflicts with taking Reiki training? If yes please explain, otherwise type "No" *

Which course date are you applying for *

January 18-19, 2025

February 15-16, 2025

March 15-16, 2025

Do you need special accomodation for attending this course? If yes please explain, otherwise type "No" *

Additional questions or comments

Course Policy

Usui/Holy Fire® III Reiki Practitioner Course Deposit and Refund Policy:

The total fee for Usui/Holy Fire® III Reiki Practitioner Course Levels I & II is $395. Once the applicant is accepted for this course, a deposit of $150 is required and must be submitted no later than 7 days prior to the first day of class. The remaining balance $245 is due on the first day of class.

If the applicant cancels the course:
. At least 7 days prior to the first day of class, 90% of the deposit is refundable.
. 6 - 4 days prior to the first day of class, 50% of the deposit is refundable.
. 3 days - 1 day prior to the first day of class, or cancel on the first day of class,
or cancel at any point once the course began, the applicant receives zero refund
of the deposit.

If a course must be canceled due to severe weather conditions, sudden illness, or unexpected personal emergency, the deposit is allowed to be transferred to another course date for one time only. Outside the time frame allowed for deposit refund, there will be no refund for the payment of the course fee regardless of the reason.

Please check the box below to affirm that you have read and agreed to comply with the deposit and refund policy for this course.
*

I affirm that I have read and agreed to fully comply with the deposit and refund policy for the Usui/Holy Fire® III Reiki Practitioner Course Levels I & II

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Minimum Age Requirement:

The applicant must be at least 18 years of age to apply for Usui/Holy Fire® III Reiki Practitioner Course Levels I & II. Check the box if you meet the age requirement.
*

I affirm that I am at least 18 years of age as of the date of this application.

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Release of Liability:

The applicant shall fully release April Bui-Instructor and Dharma Reiki & Acupuncture clinic including all of its staff members, associates, and volunteers from any liability for claims of injury, loss, or damages resulting from the applicant's voluntary undertaking of this course and the applicant's voluntary use of the facility at Dharma Reiki & Acupuncture clinic for all the days in which the applicant attends the course and at any time in the future.

The applicant understands that if the applicant has any special health conditions or any other conditions which the applicant believes may be adversely affected by taking Reiki training, it is the applicant's responsibility to inform the course instructor about the applicant's condition(s) or needs prior to taking this course.
*

I, the applicant have read and agreed to fully comply with the Release of Liability policy of this course.

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Applicant's Affirmations and Consent for Electronic Submission of Application:

I, the applicant affirm that by electronically signing this application, I have read, understood, and agreed to fully comply with all parts of the Course Policy effective as of the date of this application and at any time in the future.

I affirm that my electronic signature in this application authorizes the transmission of this application and all my information in this application electronically.

I understand that Dharma Reiki & Acupuncture does not share, sell, rent, or trade any of my information in this application. I understand that this online application form is serviced by Formsite and my data may be accessible by Formsite and their affiliates for the purpose of maintaining and regulating their services in accordance with their privacy policy. I understand that Dharma Reiki & Acupuncture has no control and no authority over the privacy policy and the usage of data collection of its online-service provider Formsite and any affiliates of Formsite.

I understand that I have the option of filling out a paper application for this course.

I understand that my electronic signature is legally binding as defined by the Federal ESIGN Act.
*

By checking this box, I affirm my voluntary use and submission of this application form electronically.

Applicant's Electronic Signature *

Today's date * +

Thank you for your interest in Usui/Holy Fire® III Reiki Practitioner Course Levels I-II. Please note that your application is subject to review. We will be in touch with you as soon as the review of your application is completed.