Sex? MaleFemale

Full Name (First, Middle, Last)

Address

City

State/Provence/Territory

Country

Zip/ Postal:

Telephone (mobile) for texting:

Email

Nationality:

Occupation

Emergency Contact Name, Relationship to You

Contact Address (City, State, ZIP & Country)

Emergency Contact Phone & Email

How did you learn of this retreat?

Please list meditation retreats you've attended in the past. Include: Date, Teacher, Location, and length.

If you have attended any previous retreats with Alan, please list them.

Please explain in a sentence or two why you want to attend this retreat.

What (if any) psychological and mental health issues have you had in your life, past or present?

Please list any medication you are currently taking for these issues.

Please list any dietary restrictions that are essential for you during the retreat.

Do you have any special needs or concerns that we should be aware of?

How will you pay for your $300 USD food costs? Pay Pal? Credit Card? Check? Other? Pay PalCredit CardCheckOther

Upon acceptance to attend the retreat a $300 (non-refundable) food fee must be made.

I hereby certify that all of the information contained in this application is complete and accurate to the best of my knowledge. I understand that, if accepted, omissions or false statements on this application shall be considered sufficient cause for dismissal. I will not hold World Dharma, the Buddha Sasana Foundation, or Gymea Eco Retreat & Spa responsible for any liability during my travel or stay at this retreat. Namaste

Δ