Request edit access
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
Email address *
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
Required
Are you currently being treated by a physician? *
Are you mobility-impaired and rely on support?
Check if applicable
How often do you practice a specific style of meditation? *
Choose the answer that best describes your experience
How long have you been practicing meditation if any ? *
Choose the answer that best describes it
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
Menu Selection *
How will you get there? *
Required
Questions?
Contact Jordan at TheScottJordan@gmail.com and enter your comments below.
Your answer
Will you pay with Check, Credit Card or PayPal?
Make your payment using the on the Website payment button
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms