Family name

Cette question est obligatoire.

Name

Cette question est obligatoire.

Gender

F
M

Cette question est obligatoire.

Date of birth

ddmmyyyy

Cette question est obligatoire.

Address: street & number

Cette question est obligatoire.

Address: postal code, city, country

Countries like on licenseplate of cars (e.g. NL, D, I)

Cette question est obligatoire.

Telephone

Preferably cell-phone so that you can be reached during arrival

Cette question est obligatoire.

Email address

Cette question est obligatoire.

Telephone or contact address

of a friend in case of emergencies

Cette question est obligatoire.

Type of room

Twin, shared bath
Twin, private bath
Single, shared bath
Single, private bath

Cette question est obligatoire.

Payment

Will pay deposit now and remainder latest September 1, 2014

Agrees

Cette question est obligatoire.

Agreement

If you are (or have been) under treatment of a psychiatrist or are taking psychoactive drugs, you are requested to discuss with your doctor and meditation teacher whether participation is fitting at this moment in time. You can reach Henk Barendregt by email <hbarendregt@gmail.com>. Participant declares: "I register for mentioned period of retreat and have the intention to keep the rules of the retreat as much as possible. I know that I cannot keep the supervisor(s) responsible for my personal development. The supervisor(s) will give their best effort to support the participants to develop mindfulness for the sake of their progress."

Agrees

Cette question est obligatoire.

Meditation experience

type of meditation & teacher (no experience required)

Cette question est obligatoire.

Comments

(Optional)

Cette question est obligatoire.

14Corfu