Your full name:

City, state or province and country: ):

Email address (best one--that you check regularly):
CSRM session you are applying for (date of first meeting):
How long have you been a Chios Master Teacher?
Approximately how many total times have you practiced Chios Meditation (number of sessions)?
0-5
6-10
11-20
More than 20
Have you carefully read the instructions for Chios Meditation and are you confident you are practicing
Yes
No
Not Sure
the technique correctly?
How settled, comfortable and confident do you feel in your practice of Chios Meditation (scale of 1-5)?
(1) Not at All
(2) Somewhat
(3) Average
(4) Very
(5) Extremely
How many Chios group meditations have you participated in?
Please choose a six digit PIN code (six numbers, no letters or symbols):
Write down your PIN code and keep it in a safe place (it will be required to open your course materials).
Exact way you want your name to appear on your degree certificate:
Please read the following carefully. If you agree, please sign in the space provided.
If accepted into the course I agree that, in consideration for being taught the valuable knowledge therein:
1. I will keep all knowledge and techniques taught in the course completely confidential. I will not furnish
the course manual (including any future editions) or any portion of it to anyone. I will not reproduce the
course manual (including any future editions) or any portion of it, the information in it or the means of
practice of the techniques in it (including any future versions or additions to techniques) in any way or
form, including electronic, mechanical, photocopying, audio or video recording, or in a book, article or
any other form of publication, or place it into any information storage system, network or on the Internet.
2. I will use the techniques taught in the course only for the healing purposes and applications taught as part
of the course, will not combine or use them with techniques from any other healing art, and will not
employ them for any other purpose or use. I will use the techniques and knowledge taught only for
positive, ethical and healing purposes.
3. I will not incorporate or teach any of the knowledge and techniques taught in this course into my Chios or
any other teaching work unless and until authorized to do so.
Typing my full name below is my electronic signature and full agreement to the above:
Name:

Date:

Be sure all items above are complete. Attach saved PDF to email and send to: SuperRadiance@chioshealing.com