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Retreat Application Form

Please fill your detail in this form to make a reservation.


Personal Details

  • Female
  • Male
From
To

Meditation Practices

  • Yes
  • No
  • Yes
  • No


Emergency Details

In case of emergency, please contact:


Health Details

In order for us to best serve each participant on the retreat, please answer the following questions. All answers will be kept strictly confidential.



  • Yes
  • No
  • Yes
  • No
  • Yes
  • No
  • Yes
  • No
  • Yes
  • No
  • Yes
  • No

If you answered "Yes" to any of the questions above, give details of all occurrences.
Include the following: dates, frequency, type, amount etc below

If you have any questions that you wish to discuss prior to participating in the retreat,
please do so before committing yourself to the program.

I acknowledge that I have read and understood the notes about the retreat and the rules set down and I agree to abide by them. I realise that a Meditation Retreat is a serous undertaking that will require my full mental and physical health and I certify that I am fit to undertake it.


I certify that all information above to be true and correct.