Journey Within

Primordial Sound Mantra Application
and Registration Form

THANK YOU FOR YOUR INTEREST IN TRANSFORMING YOUR LIFE AND YOURSELF THROUGH INNERLIGHT AWAKENING OPPORTUNITIES!

To apply for the program, you must fill out the application form completely.
Your thoughtful answers will give me the info I need to take you where you want to go.
Once you click submit, I will contact you within 2 business days to pay the deposit or fee depending on how close the start date is..

Name

First Name

Last Name

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Are you:

Female

Male

Age:

Occupation

Date of Birth

YYYY

Place of Birth

City, State, Year

Time of Birth

Be sure to note am or pm

Do you currently have a meditation or mindfulness practices? If yes, please describe.

Have you ever been instructed in a mantra meditation technique?

Yes

If yes, which one?

Date Instructed and Do you Still Practice it?

How is your mental health?

How is your physical health?

Emergency Contact Name and Number

Are you registering for an online seminar or a Tulsa, Oklahoma seminar?

Yes

Signature - Enter your Name (to serve as your signature) and Date

My decision to learn Primordial Sound Meditation (PSM) is a personal decision. I have not been made any guarantees that I will receive any specific results. I understand the PSM is not a substitute for treatment or services ordinarily provided by health care professionals for physiological or psychological complaints. I further understand that any instruction given to me during the PSM is for me personally and may not be appropriate for others. I hereby agree to hold Dian Shirley InnerLight Awakening, the Chopra Center, LLC, and their officers, agents, and employees harmless in any claims brought by me, or on my behalf, which contradict the above. Entering my name below constitutes my acceptance of the conditions expressed in the agreement.

Dian will contact you to make a non-refundable deposit of $150.00 with application to cover mantra and costs of included materials. If paid in full at time of registration, the seminar cost is $350.

Cancellation Policy: If for some reason you cannot attend the seminar you have enrolled in, your mantra will be held until you can attend a future seminar or schedule private instruction.

Journey Within

Primordial Sound Mantra Application
and Registration Form

YOGA

ONE TO ONE COACHING

MEDITATION

AYURVEDA

Journey Within

Primordial Sound Mantra Applicationand Registration Form

YOGA

ONE TO ONE COACHING

MEDITATION

AYURVEDA

Primordial Sound Mantra Application
and Registration Form