Winter Meditation Intensive 2019

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* These fields are required

1 Welcome

3 People in your group

Guest 1		First Name	Last Name	Email	Gender
Guest 1		First Name	Last Name	Email	Gender

After completing this form, emails will be sent to everyone in your group to complete their information.

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4 Optional Items

5 Participant Info

Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Gender *
Birth Date *
Emergency Contact Info (Name and Phone Number) *
Requested Roommate
Registration Type *	Please indicate the participant type you are registering as. Scholarship and Fellowship applicants must also fill out the required applications. Please click the appropriate link to apply: Scholarships, Fellowships
Volunteer Staff Role *
Terms and Conditions Retreat Staff Volunteer *	I have read the three policy documents listed below and agree to adhere to all terms and conditions listed therein. Dual Relationship Policy Code of Conduct Right Speech Policy
Terms and Conditions Retreat Participant *	I have read the four policy documents listed below and agree to adhere to all terms and conditions listed therein. Liability Waiver Retreat Requirements Code of Conduct Registration and Program Policies
Terms and Conditions Retreat Fellowship *	I have read the four policy documents listed below and agree to adhere to all terms and conditions listed therein. Liability Waiver Retreat Requirements Code of Conduct Registration and Program Policies
Terms and Conditions Retreat Scholarship *	I have read the four policy documents listed below and agree to adhere to all terms and conditions listed therein. Liability Waiver Retreat Requirements Code of Conduct Registration and Program Policies
Please describe your practice history and inspiration for attending this program. *
Dietary Preference *	Omnivore Vegetarian Vegan
Please list any dietary allergies. Please also indicate if exposure would require medical attention (i.e. anaphylaxis due to peanuts). *
Do you have any serious allergies (e.g. bee stings, penicillin, nut allergies, etc.)? If yes, please specify and explain how we should best respond in the event of a medical emergency. *	Enter "none" if you have no issues
Do you need a chair for sitting meditation? *	Yes No
Do you have any mobility issues that affect your use of stairs or walking? If so, please describe. *
Do you have hearing loss (even mild) that sometimes requires assistance? If so please describe. *
What current or past medical or physical conditions are important for us to know about? Would any of this prevent you from doing chores during the program? *
Have you ever received inpatient care for psychiatric, mental health, or addiction issues? If yes, please describe. *
What prescription medications are you currently taking or have taken in the past six months for physical, psychiatric, mental health, or addiction issues? *
Do you have concerns about engaging in intensive meditation practice at this time? Do others close to you (such as medical professionals, mental health professionals, or family members) have concerns? *
Is there anything else we need to know about your registration? *
How did you hear about this program?
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1 Welcome

2 Program Fees

Select an option*

BMRC* Private Suite - Queen

BMRC* Private Suite - Full

BMRC* Private Suite - Twin

BMRC* Private Suite - Double Twin

BMRC* Private Room - Full

BMRC* Private Room - Twin

BMRC* Shared Room - Double Twin

BMRC* Dormitory - 4 Person

BMRC* Dormitory - 12 Person

BMRC* Fellowship Housing

BMRC* Scholarship Housing

BMRC* Staff Housing

3 People in your group

4 Optional Items

5 Participant Info

6 Donate

7 Payment