Personal Retreat Request
BUDDHIST INSIGHTS
Address: 504 Beach 68th Street, 11692 Arverne (Entrance On Thursby Avenue)
Contact us at RSVP@buddhistinsights.com
Email address *
First Name *
Your answer
Last Name *
Your answer
Age *
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Address *
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Phone Number *
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Emergency Contact (Name & Phone Number) *
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When would you like to come on Retreat? (Please specify arrival - departure date & Time) *
Your answer
Please describe any needs/expectations. *
Your answer
Why would you like to do your retreat at the Rockaway Summer House? *
Your answer
Do you identify as a person of color? *
How do you identify your gender? *
Would you like to sleepover at the retreat center? *
Do you snore? *
Which dorm would you prefer to be in? *
If your preferred dorm is not available, are you comfortable sleeping in the all-gender dorm? *
How many retreats have you participated in and how long was the longest retreat you attended? *
Your answer
Have you participated in any Buddhist Insights events before? (If yes, specify if retreats at the Summer House, classes, etc.) *
Your answer
Do you have any mobility limitations? (If yes, please briefly describe them) *
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Will you need to sit in a chair? *
Do you have any history of mental illness? (If so, please briefly describe your past and present conditions) *
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Are you currently taking any medications? (If so, please list the medications and why you are taking them) *
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Do you have any allergies? *
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Do you have kitchen experience? (If so, please describe what kind of kitchen experience you have) *
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How did you hear about Buddhist Insights? *
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Comments and/or questions
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By signing, I assume full responsibility for any and all damages, which may incur through participation. I affirm that a licensed physician has verified my good health and physical condition to participate in such program. In addition, I will make the retreat coordinator aware of any medical conditions or physical limitations before the program. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to practice any activity and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Buddhist Insights and its instructors. I hereby grant Buddhist Insights permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its marketing materials or publications, including web-based publications, without payment or other consideration. [PLEASE ENTER YOUR INITIALS] *
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