FSSapplication

Free Spirit School Student Application Form

First Name

Last Name

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Fax

Email

Verify Email

Birthday (month/day)

The following questions are necessary for you to complete in order to be considered for acceptance into the program. All information you share is kept confidential.

1. In a brief statement please share why you are interested in attending the Free Spirit School of Integrative Energy Healing
Program:

2. Please list all medical conditions:

3. Please list all medications and over the counter products you are
currently taking. Include vitamins and supplements.

4. Do you have any special needs?

Yes No

If Yes, please specify:

5. Please check the usage and frequency of the follow:

Alchohol

None 1-2 times per week 2-3 times per week 4 or more times per week Daily

Tobacco

None 1-2 times per week 2-3 times per week 4 times per week Daily

Recreational Drugs

None 1-2 times per week 2-3 times per week 4 or more times per week Daily

If you marked any usage, please specify type and quantity:

6. Have you ever been treated for a mental or emotional condition or has there ever been a recomendation that you receive treatment?

Select an option

Yes No

If Yes, please specify:

7. Have you ever been treated for psychological difficulties or has there ever been a recommendation that you be treated for these difficulties? Please provided type and date.

8. Please list all therapeutic, spiritual or counseling groups in which you currently participate in for support and development:

9. Provide a list and description of any training, certificates or degrees that you have earned:

Do you have your own healing practice or other service oriented profession (e.g.. massage, nursing, Reiki, Physical or Occupational Therapy, etc.)?

Yes No

If yes, please specify:

The Free Spirit School of Integrative Energy Healing is not a licensed medical care service. The healing work you participate in is not a replacement for medical care. It is recommended that you openly discuss whatever services you participate in with your medical provider in order to facilitate optimum health and wellness. If you require the care of a licensed health care professional, please contact your state's medical and/or psychological board.

I understand and agree to the above statement

I hereby state that I have not been convicted of, entered a plea of nolo contendre, guilty of, or deferred adjudication to crimes or offenses of a moral or criminal nature within the past seven years.

True False

My answer to the preceeding question is correct to the best of my knowledge.

I release the Free Spirit School of Integrated Energy Healing of any responsibility from psychical, psychological or spiritual conditions that may arise from participation in the programs, classes and activities.

I understand and agree to the above statement

I acknowledge that all the information on this form is accurate and true to the best of my knowledge.

I understand that class fees are $250.00 per weekend which must be paid before you come to class. Tuition is not refundable.