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NeuroAwakening Thanksgiving Retreat Registration 2017
Neurofeedback Enhanced Meditation, November 24-26, 2017. Please complete one form per person.
Email completed form to
TheScottJordan@gmail.com
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Email
*
Your email
Echo Rock Neurotherapy Retreat at St Francis Center
First Name
*
Your answer
Last Name:
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State/Province
*
Your answer
Postal Code
*
Your answer
Country
Your answer
Cell phone
*
Your answer
Have you experienced neurofeedback at EchoRock Neurotherapy?
*
check the statement that best applies
no
yes
Required
Are you currently being treated by a physician?
*
Choose
Yes
No
Are you mobility-impaired and rely on support?
Check if applicable
I use a wheelchair.
I use a cane.
How often do you practice a specific style of meditation?
*
Choose the answer that best describes your experience
Choose
four or more days a week
once a week on average
once a month on average
once in a while
Never
How long have you been practicing meditation if any ?
*
Choose the answer that best describes it
Choose
Beginner
1-2 years
3-10 years
10+ years
Briefly describe your meditation experience.
*
Your answer
Do you have special dietary or medical needs?
A retreat manager will follow up to review your special needs.
Your answer
Room Selections
*
Single men and women are quartered separately. Cabins available for partners in relationship
Choose
Single Female
Single Male
Double for me and my partner
Menu Selection
*
Vegetarian, includes dairy
Non-vegetarian
Gluen Free
How will you get there?
*
By car
By air, will arrange my own ground transportation.
Required
Questions?
Contact Jordan at
TheScottJordan@gmail.com
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Will you pay with Check, Credit Card or PayPal?
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