Pranic Healing Workshop Registration Form

To register for one of the Pranic Healing Workshops, complete the form below and complete your payment. You may submit the form online by clicking the Submit Registration Form button, or you may print and mail the form with your payment, made out to Miriam Smith.
Send to: Miriam Smith, 29 Buckingham Road, North Andover, MA 01845

You also may submit payments via PayPal by going to the Pranic Healing New England Payments page.

Pranic Healing Workshops
Please select your workshop(s) Level 1, May 12-14 [Mechanicsville, Virginia]
Level 1, June 2-4 [North Andover, MA]
Student Status New Student | Review Student
Name
Address
City/State/Zip
Date of Birth
Phone Number
E-mail address
New Students Only
→ How did you hear about Pranic Healing?
→ If someone referred you to Pranic Healing, who was it?
Review Students Only
→ When did you take PH Level 1?
→ Where did you take it?
→ Who was your teacher?
Confidential Student Data [all students]
For your safety please answer the following questions.
Do you smoke? Yes | Rarely | No
Do you take drugs? Yes | Rarely | No
Do you drink alcoholic beverages? Yes | Rarely | No
What is your diet? Vegetarian | Non-Vegetarian
Have you been diagnosed or had history of contagious diseases or other illnesses? Yes | No
If yes, please specify.
Do you have history or present serious physical or psychological disorders? Yes | No
If yes, please specify.


Payment Choice
(payment must be received to complete your registration)
I am paying via PayPal.
I am sending a check.
Signature:

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