Reiki Class Registration Form - Self Care with Kimeiko

First Name *

Last Name *

Introduction

Congratulations on beginning or furthering your Reiki journey!

Before completing this form, please confirm class availability and your eligibility to participate with Kimeiko Hotta Dover (she/her/hers), Karuna Reiki(R) Master, at reiki@kimeiko.com or (647) 557-6578.

When you are ready to register, please answer the following questions. You do not need to complete this form if you have already taken a class with me.

About You

Preferred name (if different from legal name above)

Please type your name EXACTLY as you'd like to appear on your certificate *

Preferred Pronouns *

Email *

Phone *

Mailing Address *

Reiki class

Which class are you registering for? *

What is the date of your desired class? *

Audio / visual permission

May I take your picture? *

NoYesNo

After you have had a chance to review class pictures, I may share your pictures: *

Referral

How did you hear about us? *

Please let me know who referred you so I can thank them!

Reiki Class Registration Form - Self Care with Kimeiko

Thanks for completing the form.

The information has been received.