retreat name - Registration form
Confidential retreat registration form, please complete and click submit
Name *
Gender and Age *
Email *
Phone *
Address *
Contact in case of Emergency During the Retreat *
Dietary Requirements
Transport: Can you offer a lift or would you like a lift?
Current meditation practice if any *
Previous retreats attended *
Care and Support - please answer the following questions so that we can care for you appropriately. Do you have any current or previous diagnosis or treatment of a psychological or psychiatric illness? e.g. mood disorders, panic attacks, schizophrenia, clinical depression, generalised anxiety disorder. *
Do you have a medical conditions that could require attention or would affect your participation in meditation sessions? e.g. epilepsy, chronic back pain, chronic fatigue *
Do you have a drug and/or alcohol addiction issues (e.g. marijuana, amphetamine, heroin, ecstasy, alcohol etc…) *
Do you have any additional information or comments you would like to add to this form?
How did you hear about us?
By checking the box below, I confirm that all of the above information is correct to the best of my knowledge. I will inform the teachers/managers of any change in my circumstances. *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy