Please provide the following contact information and the address information where the class/meeting will take place:

*First Name
*Last Name
* Phone
*E-mail
Please provide the following information for the location of the class/meeting:
Group Name
Number in Group
Company/Building Name
Meeting Street Address
Meeting Suite/Apt
Meeting City
Meeting State/Province
Meeting Zip Code
Web Site Address:

Are you an active client of Jan's?

Yes        No

If not, how do you know Jan?

Have you done EFT before?

Yes        No

If yes, with whom?

Please provide at least two (2) proposed dates and time for the class/meeting.

Please provide three (3) topic suggestions that you would like to have addressed in this class.  Jan will pick one.

Please indicate any other area(s) of interest you may have by checking the applicable box below (select all that apply):

EFT Personal Sessions
EFT Certification
Products (CD's, Cassettes, Literature)

Please tell us how you heard about us:

Web Site Friend Relative Business Associate Church Other

While EFT has produced remarkable results, it must still be considered to be in the experimental stage and thus the public must take complete responsibility for their personal use of it.   Those who want to discuss the use of EFT for a specific emotional problem with a professional in the mental health field may contact Jan for the name and phone number of a local licensed professional or contact www.emofree.com for a practitioner near you.

PLEASE DO NOT ATTEMPT TO PRACTICE EFT WITHOUT SUPERVISION.  Properly applied, these procedures will work across the board.  However, for some people, it may create distress to explore emotional issues unattended.  If you are under a physician's or physiatrist’s care, on serious medications or consider yourself otherwise vulnerable, PLEASE DO NOT ATTEMPT TO DO EFT ON YOU OWN.

DISCLAIMER

The Rejuvenation Station, LLC, and Jan Luther (hereinafter referred to as “TRS, LLC”) make no claims, implied or otherwise, regarding the success and/or results from the application of EFT, TAT, REIKI and/or personal coaching/counseling (hereinafter referred to as “services”) provided by TRS, LLC.  These services are considered experimental and although success rates are in the 80%-90% range, they are as yet undocumented therapies.  Jan Luther is NOT a licensed physician, therapist or psychologist.  Jan Luther is operating under an Art of Healing Privilege business license in the State of North Carolina and holds certificates/licenses as EFT-MASTER Practitioner, TAT practitioner and trainer, Reiki Practitioner and ordained Minister/Director of Universal Brotherhood Ministries.  The emotional or physical frailty of some people is such that they should not attempt ANY healing procedure without the presence of a LICENSED THERAPIST.  This may be 2% - 3% of the population.  If you are in this category, YOU MUST BE ACCOMPANIED BY YOUR MENTAL HEALTH CARE PROVIDER!  You take full responsibility for your personal health and safety.  Your compliance with all of your current medical treatments, therapies and prescriptions is expected.  TRS, LLC, shall not be liable for any damages or injury arising out of your access to, or inability to access, the services provided.  TRS, LLC, disclaims any and all liability for direct, indirect, incidental, consequential, punitive and special or other damages, lost opportunities, lost profit or any other loss or damages of any kind.

RELEASE

By clicking on the Continue to Registration link below, I affirm that the information I am providing is accurate and true and that I freely enter into this legally binding agreement and acknowledge that I understand and agree with the disclaimer presented above.  Also by my clicking on the Continue to Registration link below, I, and my heirs, in consideration of my participation in the services provided by Jan Luther and/or The Rejuvenation Station, LLC, hereby release Jan Luther, her family and the officers, employees and agents of The Rejuvenation Station, LLC, from any and all liability for any loss or damage caused, or alleged to have been caused, directly or indirectly, by the services provided and/or the information or ideas contained, suggested or referenced during the course of the services provided.  I understand that my participation in the services provided is strictly voluntary, at my own risk and I freely choose to participate.   I understand that all tele-classes are recorded and that by agreeing to these terms and conditions, I authorize Jan Luther and The Rejuvenation Station, LLC, to use these recordings without limitation or restriction.  I further understand that I will receive no compensation for their use.  I understand that Jan Luther and The Rejuvenation Station, LLC, do not provide medical treatments and/or coverage and I verify that I will be responsible for any and all medical costs I incur, directly or indirectly, as a result of my participation.

I agree that (1) I have not modified this form from its original and (2) Jan Luther nor anyone working with her will have any liability to me for any damage to my emotional or physical health arising in any way whatsoever out of my participation or my use of the techniques.

DISCLOSURE

Jan Luther is an ordained minister and Life Skills Coach, not a licensed physician.  As a Reiki Master and Spiritual Counselor, her self-regulated holistic treatments and specialties are offered through her company, The Rejuvenation Station, LLC.  Jan operates this business under the dictates of North Carolina Law and has a current “Art of Healing” business license. Her client-centered disciplines, philosophy, education, experience and certifications allow her to provide services that are alternative and complementary.

Jan offers the following services.  (Her certifications, education, training, experience and other qualifications regarding these services are also indicated.)

1. Emotional Freedom Techniques (EFT) - EFT Certification, July 2002, EFT Advanced Certification, March 2004, EFT MASTER Certification, April, 2006.

2. TAT - TAT Certified Practitioner & Trainer, June 2004.

3. Usui Reiki - Reiki Certification, 1996, Reiki Master Certification, November 2003.

4. Ministerial, Pastoral Counseling or Intuitive Spiritual Counseling.  Ordained Minister with the Universal Brotherhood Ministry, December 2001.

5. Chaplain Services - Unity of Charlotte Chaplain, January 2003.

These services are not licensed by the state, but are sanctioned under the Bylaws of Universal Brotherhood Ministry where Jan Luther is an active Ordained Minister.  The services provided do not include the practice of medicine or psychology or any other licensed healing art since she is not a licensed physician.

 

AGREEMENT TO TERMS & CONDITIONS

By clicking on the Submit Registration button below, you are indicating that you agree to the terms and conditions set forth above and release Jan Luther and The Rejuvenation Station, LLC from all liability, now and in the future.