Holiday Retreat Registration
Vipassana Retreat for Everyone with Nick Hertzmark and S'akti Rose
Friday, Dec. 14 to Tuesday, Dec. 18, 2018 and
Friday, Dec. 21, 2018 to Tuesday, January 1, 2019
Email address *
First Name *
Your answer
Last Name *
Your answer
Street Address *
Your answer
City, State, Zip *
Your answer
Phone numbers (list all, indicating cellphone) *
Your answer
Date of birth *
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Gender identification *
Arrival Date *
Dec. 14, Dec. 21, or Dec. 30; teacher's permission is required for alternative date
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Departure Date *
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Interim
I will be staying at Dhamma Dena for all or part of the interim (Dec. 18-21)
Ride Needed from Palm Springs Airport? (Arrival)
Please estimate your flight arrival time, with AM or PM
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Time
:
What is your Arrival Airline & Flight Number?
Your answer
Ride Needed to Palm Springs Airport? (Departure)
Please estimate your flight arrival time, with AM or PM
MM
/
DD
Time
:
What is your Departure Airline & Flight Number?
Your answer
Special Dietary Needs
Please note that we will be offering gluten-free options for all meals.
Do you have any special needs for housing, or for your health?
Your answer
Have you attended a retreat at Dhamma Dena before? *
Are you new to Vipassana meditation? *
Where did you hear about the retreat? *
Required
Scholarship/Work Exchange Requested
$100 deposit
NOTE: Your registration is not confirmed without a deposit
A copy of your responses will be emailed to the address you provided.
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