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
Echo Rock Neurotherapy Retreat at St Francis Center
Have you experienced neurofeedback at EchoRock Neurotherapy?
check the statement that best applies
Are you currently being treated by a physician?
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
four or more days a week
once a week on average
once a month on average
once in a while
How long have you been practicing meditation if any ?
Choose the answer that best describes it
Briefly describe your meditation experience.
Do you have special dietary or medical needs?
A retreat manager will follow up to review your special needs.
Single men and women are quartered separately. Cabins available for partners in relationship
Double for me and my partner
Vegetarian, includes dairy
How will you get there?
By air, will arrange my own ground transportation.
Contact Jordan at
and enter your comments below.
Will you pay with Check, Credit Card or PayPal?
Make your payment using the on the Website payment button
Send me a copy of my responses.
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service