Breath Circles COURSE REGISTRATION

BREATH CIRCLES TO HEAL THE DIVIDES
COURSE REGISTRATION

REGISTRATION
Breath Circles to HEAL the DIVIDES ™ Online Course Form

* Indicates required field

Name *

First

Last

Address *

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City

State

Zip Code

Country

Phone Number *

Email *

How did you hear about the course? *

What Course DATES are best for you: Weekends or During Week *

NAME YOU WANT ON YOUR CERTIFICATE: *

First

Last

*NOTE: Please use the comment box if necessary to fill out the answers to these questions. They are very important questions and must be answered with honesty.

There are some contraindications for the practice of Breathology which is why your answers are important.. Breathology offers very simple, yet powerful techniques that can be "life-changing". Transformation can also stimulate health and emotional challenges while opening the door for great evolution.

Once registered, review all preparation materials and complete the short personal interview.

As a system we are seeking Breath Circle Leaders who will serve in a responsible way with standards and procedures that they commit to in this training model for its effectiveness, replication and integrity. .

Thus, PositivEnergyWorks reserves the right to accept or reject any applicants based on the answers to these questions. “Thank you for your interest in PositivEnergyWorks™ and its services

WE LOOK FORWARD TO YOUR REGISTRATION HERE:
x

Please Check If You: *

are pregnant. [Due Date] have ever been hospitalized for psychiatric or medical reasons are taking any medications. [Which?] are currently in therapy or any support group had complications at your birth (Caesarian, Late or Early born, Anesthesia, Multiple births, etc.) have attempted or seriously considered suicide [note details] are currently experiencing a “spiritual or emotional emergency” currently have an infectious or communicable disease

Comment *

Is there anything else about your current physical or emotional status that we should be aware of? If you answered yes to any of these questions, please explain. *

Note any specific limitations, illnesses or health challenges not mentioned: *

Any personal history of mental illness, depression or emotional disturbance? Please explain in detail and when: *

Any personal history of substance abuse, drug usage, drinking or medications? Please and explain and when: *

Why do you want to take this course and become a Certified Breath Circle Leader *

PARTICIPANT RELEASE STATEMENT

I do hereby agree to release Sekou Ayo Handy-Kendi, CEO and proprietor of PositivEnergyWork, LLC™ (PEW) its principals,
directors, agents, trainers, facilitators, contractors, advertisers, sponsors, and facility property owners and operators, and any
individual or organization associated with PEW from any and all liability for personal injury, or loss of, or damage to, personal
property or possessions of any individual attending or associated with PEW whether or not caused by negligence.

I further assume all risk of injury or loss from participation in the programs of PEW, including but not limited to: breathology,
breathwork, meditation, bodywork, healing touch, yoga, sound therapy, guided imagery/visualization, relaxation techniques,
laughter, EFT, ceremonies, rituals, toning, Reiki, essential oil aroma therapy, massage, reflexology, alternative/complimentary
therapies or any other form of participation in their course of study, instruction or experiential sessions.

I further understand that PEW assumes no liability for any program and/or product performance and if there are any concerns, it is recommended that I check with my physician, therapist or other licensed health care provider before engaging in any of the above-mentioned activities.

IMPORTANT: Due to virtual participation and launch objectives, registrants must agree to keeping their gallery view available, and be willing to be screen shot with agreement that all photos are reserved as the right of PEW. All Videos of sessions will be recorded and possibly used for P.E.W.'s future workshops, video products, or presentations, with all rights to footage reserved as the right of P.E.W./s

Signature *

I have read, understand and am in full agreement with the above RELEASE STATEMENT:

Name and Date *

For Minor Applicants *

I am the parent and/or guardian of the above minor and hereby endorse this Agreement on his/her behalf.

Name and Date *

Submit

COURSE PAYMENT

Breath Circles For Race, Diversity & Gender Healing

$80.00

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GENERAL PUBLIC PAY & REGISTER HERE

Breath Circles For Race, Diversity & Gender Healing

Certified Optimum Life Breathologist click Here

For a Waiver Application Payment Waiver, Reduction or Delay Application click Here

BREATH CIRCLES TO HEAL THE DIVIDESCOURSE REGISTRATION

REGISTRATIONBreath Circles to HEAL the DIVIDES ™ Online Course Form

Breath Circles For Race, Diversity & Gender Healing

BREATH CIRCLES TO HEAL THE DIVIDES
COURSE REGISTRATION

REGISTRATION
Breath Circles to HEAL the DIVIDES ™ Online Course Form