West Norfolk Hypnotherapy and NLP

Booking Form For Reiki Training And Agreement

Training held at 5 Little London Road, Northwold, Thetford, Norfolk, IP26 5NQ. This information on this form will be held in the strictest confidence. It is important that you read, fill in, sign this form returning it with your deposit or course payment to the above address. Cheque made payable to ‘The Green Balance UK Ltd’ please.

NAME:          ________________________________________________________

ADDRESS:     ________________________________________________________

                   ________________________________________________________

                   _________________________    Postcode: _____________________

Telephone No: ___________________       Email:  _____________________________

Date of Birth: _____________ Name to appear on the certificate ________________

If you require a receipt   Yes/No  Email/Paper          Directions to course Yes/No  Email/Paper

Have you suffered from any of the following:

Depression                                                                                 YES/NO

Epilepsy                                                                                      YES/NO

Any psychiatric condition                                                  YES/NO

Are you taking any medication or self-  medication   YES/NO

Any serious condition, illness or operations               YES/NO

Phobias                                                                                      YES/NO

Any mechanical or electronic devises fitted eg pacemakers                  YES/NO

If YES to any of the above please give details (Continue on reverse if necessary)

 ________________________________________________________________

 ________________________________________________________________

Course Date(s)______________________  Course(s) Fee(s)_________________

Amount Enclosed____________________ Remainder to pay_________________

 Full payment to be made prioir to course date or at the start of the course by cheque or cash unless otherwise agreed.

All course fees are non refundable, however maybe transfured to future course.

In the unlikely event of the course being cancelled, no liability can be acepted by the organisers for any assosiated costs, including, but not limited to travel and accomadation.

Animal visitors to the course (if applicable), any close contact with animals is at your own risk. The organisers accept no responsibility for damage or injury caused by and animal.

I AGREE BY THE TERMS OF PAYMENT AND RESPONSIBILITY FOR THE COURSE.

Signature: _________________________________   Date: ________________

Information on how to gain the maximum benefit from your training will be sent out 7 days before the course commences provided the deposit has been received. Please print off form and send to above address with Cheque.