2018 Winter Retreat Questionnaire: starts Friday, Dec. 28 - Copper Beech Institute
Please fill in the information below as completely as possible.
If a question is not applicable, please leave it blank.
Email address *
Name *
If you use a different name for your PayPal or bank check payment, please indicate it in parentheses so we can match you with the correct registration payment.
Your answer
Phone Number
Optionally, please provide your phone number with area code. Cell phone # is preferred, in case we need to reach you once you're at the program.
Your answer
How did you hear about this retreat?
Or, who were you referred by?
Your answer
Meditation experience *
Please briefly describe your prior meditation experience.
Your answer
Retreat experience *
Please briefly describe your prior experience with meditation retreats
Your answer
Primary interest? *
What is your primary interest or focus for this retreat?
Your answer
Affiliations
Are you affiliated with any meditation groups or organizations?
Your answer
Do you have any food preferences, restrictions or allergies?
If you have any food preferences, restrictions, allergies, and so on, we will do our best to work with the Copper Beech staff to accommodate them. We may contact you for more details if needed.
Food allergies/other restrictions - details
If you indicated food allergies or other restrictions above, please provide details here.
Your answer
Disability assistance required?
If you need any disability assistance, please describe your needs below. Otherwise, please leave this blank.
Your answer
Other concerns?
If you have other specific questions or concerns, please let us know briefly below and we'll do our best to respond.
Your answer
Volunteer opportunities
Please mark all of the activities you are interested in helping with before or during the retreat. (Prior experience is helpful for some roles, but training is also available.)
Volunteering - Experience & Other info
Please briefly describe your experience in the above roles and add any notes regarding your volunteer service you think are helpful.
Your answer
If you need to finish filling out this form later, or need to update it later with additional details, please take note: After you "submit" the form, you will see a hyperlink that says "Edit your response". Please *save* that hyperlink so you can return to the partially completed form later and add the additional information. (It should work for you to copy & paste the hyperlink into an e-mail or a Microsoft Word document or similar.)

If you have any other questions, please contact the registrar, Ellen Balzé (ellenbalze@yahoo.com).

A copy of your responses will be emailed to the address you provided.
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