Youth Peace Retreat 2017 - Participant Form
Please fill out this form if you would like to participate in the
Youth Peace Retreat - Success From Within

The next dates are: April 21 - 23, 2017 in Novato California.
More information on the venue can be found here: http://www.anubhutiretreatcenter.org/

To participate in this retreat, the following conditions must be met:

1. You are psychologically, emotionally, and generally physically healthy such that you are able to safely participate in this retreat
2. Not currently or previously have experienced suicidal thoughts, any form of self-harm, or thoughts of hurting others or pose any kind of danger to yourself or others
3. Not have been previously hospitalized for mental health reasons
4. Have more than 1-year of recovery from any substance abuse involving legal or illegal substances
5. Able to independently manage and administer any required medically prescribed medications
6. Are able to manage any allergies to food or otherwise
7. If you have ever had an eating disorder, you are stable in recovery
8. Understand that this is an educational retreat and does not constitute medical, psychiatric, or psychological treatment
9. Understand that the retreat is a drug-free environment. No drugs or substances of abuse are permitted without a medical prescription and usage is as prescribed only

By filling out this form and continuing with the application process you certify that you meet the above conditions. Please note that a follow-up interview may occur prior to your admittance into the retreat.

Limits of Confidentiality of Information Provided:If any of the information you provide to us leads us to believe you may be in danger of harming yourself, or someone else, or that as a minor under 18 years of age, that someone is harming you, as in physical or sexual abuse, we will contact the appropriate authorities such as the police department or Child Protective Services in addition to your family as appropriate to ensure your safety.

Resources if you need support:
1. Emergency: 911
2. Teen Depression Hotline - crisistextline.org
3. TEEN LINE | Teens Helping Teens - Connect, talk, get help! - https://teenlineonline.org/
4. Suicide Hotline: 1-800-SUICIDE

If you are filling out this form for someone else, please explain below.

***IMPORTANT: If you are under the age of 18 years old, a parent or guardian must fill out the youth admittance permission form, which we will sent out closer to the retreat dates.

Full Name
Your answer
Email Address
Your answer
Phone Number
Your answer
Birthday
Your answer
Age
Your answer
Address
Your answer
Emergency Contact Name
Your answer
Emergency Contact Relation
Your answer
Emergency Contact Phone Number
Your answer
Are you currently filling out this form for yourself or someone else? If filling out for someone else, please explain who.
Your answer
Are you currently living with parents or guardians?
Parent or Guardian Contact Information
Your answer
Is this your first time at this venue?
Why do you want to be a part of the Youth Peace Retreat?
Your answer
Please tell us what your life at home is like.
Your answer
Are you currently taking any medication? If yes, please list which medication.
Your answer
(If The Answer To the Above was Yes) Will you be able to manage your own medication administration while on this retreat?
This retreat involves personal growth work that can bring up difficult emotions or memories. Do you have available outside support, such as a therapist or counselor, that you can go to for emotional support following this retreat?
Your answer
Do you have any issues with sleeping? If yes, please explain.
Your answer
Do you have any Allergies? If yes, please explain.
Your answer
Is there anything else about you we should know?
Your answer
I understand that this is an educational retreat and does not constitute medical or psychological treatment.
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