Deep Ecology Training Workshop: Earth Day! April 22nd, 2017: REGISTRATION FORM

— A DEEP ECOLOGY MONTH PROGRAM OF NEWARK CENTER FOR MEDITATIVE CULTURE —

LOCATION: Rutgers University, Smith Hall, 101 Warren St., Room 242, Newark NJ

CHECK-IN: 9:45am (Please allow ample time for parking so that you are on time for class.)

PROGRAM DURATION: 10:00am-2:00pm

TEACHER: Kazi
SPECIAL GUEST SPEAKER: Matt Gosser
GUEST PRESENTERS: Abe Gruswitz, Mesha Allen
NCMC SPEAKERS: Marcie Barth, Kamilah Crawley,

GUIDELINES TO READ BEFORE REGISTERING (REGISTRATION FORM DIRECTLY BELOW):

FILLING OUT FORM
- Registration deadline is Thursday, April 20, 2017.
- Please fill out one form for each individual attending.
- To register others, you will be prompted by a pop-up window to enter a new form after completing this one.

WHO CAN ATTEND
- This workshop is appropriate for both the curious and the seriously interested and/or engaged in deep ecology and environmental issues.
- You must be at least 18 years old to attend this workshop.
- This workshop classroom is wheelchair and elevator accessible.

LIABILITY
- This is an informal community program, therefore Newark Center for Meditative Culture (NCMC), The Medicine Lifestyle, Rabbit Hole Urban Farm Newark, Rutgers University, and any of the individuals associated with this program will NOT BE HELD RESPONSIBLE for any injuries or loss of personal property.
- Please read the Liability Waiver at the bottom of this Registration Form prior to signing.

ATTENDANCE RESTRICTION
- We ask that you attend the entire workshop in order to get maximum benefit and so as not to disturb the presentations and student concentration.

WORKSHOP SCHEDULE
- Morning Session: 10:00-12:00
- Lunch Break: 12:00-12:30
- Afternoon Session: 12:30-2:00
(We invite you to attend our closing Deep Ecology "Greening Self” Reception at Rabbit Hole Urban Farm from 2:30 to 3:30pm.)

DONATIONS
- This workshop is free, though we do welcome donations. Your generosity helps to gift the teachers and cover any expenses incurred for this program.

INFORMATION
- You will hear from NCMC prior to the workshop with final details and optional preparatory reading materials.
- You are also welcome to ask us any questions you might have beforehand. Email below.
- We do not share any of your personal information.

CANCELLATION
- We ask that you please cancel if for some reason you cannot attend. This helps us with our plans for food, other provisions, and concern about your whereabouts!

EMAIL: Contact us at info@newarkmeditation.org.

Registration Form
1) First Name *
Your answer
2) Last Name *
Your answer
3) Are you 18 years of age or older? *
4) Email Address *
If you don not have an email address, type in "none"
Your answer
5) Phone Number
REQUIRED ONLY IF YOU DO NOT HAVE AN EMAIL ADDRESS. Include area code.
Your answer
6) Address (optional)
Street, City, State, Zip Code
Your answer
7) What is your interest in this workshop? *
Required
8) What do you hope to learn at this workshop? *
Please give a short description of any main topics you are interested in.
Your answer
9) Will you join us for our vegetarian lunch? *
You are also welcome to attend lunch and bring your own room temp lunch. There will be gluten-free and vegan choices.
10) Do you plan to join us for the closing Deep Ecology "Greening Self" Reception at Rabbit Hole Urban Farm immediately following the workshop?
11) Would you like to subscribe to receive news about NCMC programs? *
We generally email just once a week.
12) Liability Waiver *
ACKNOWLEDGEMENT OF RISKS: I waive and release any and all claims against Newark Center for Meditative Culture (NCMC), The Medicine Lifestyle, Rabbit Hole Urban Farm Newark, Rutgers University, and any of the individuals associated with this program “Deep Ecology Training Workshop” to be held on Saturday, April 22nd, 2017 from approximately 10:00am to 2:00pm for any injury or illness (mental or physical) which may directly or indirectly result from my participation in this above mentioned program. The risks include, but are not limited to, those caused by terrain, facilities, meals, equipment, lack of hydration, temperature, weather, physical condition of individuals, vehicular traffic, actions of other people including, but not limited to, instructors, participants, volunteers and, spectators, event officials and event monitors, and/or producers of the event, as well as negligence or carelessness of any of these people. These risks are not only inherent to individuals, but are also present for volunteers. I state that I, and my wards if any, am/are in proper condition to participate in the event. NCMC reserves the right to refuse any entry. ASSUMPTION OF RISKS: By checking the box below and adding my electronic signature, I acknowledge that I have read the above Liability Waiver statement and I understand its content. I hereby assume all risks of participating and/or volunteering in the above mentioned program and take full responsibility for my own and my minor-aged ward’s (if any) personal safety and personal property while attending an NCMC event.
Required
13) Consent to Media *
I understand that at this event or other NCMC activities, I may be photographed. Do you allow your photo, video, or film likeness to be used for any legitimate promotional purpose by the Event holders, producers, sponsors, organizers and/or assigns?
14) Electronic Signature *
Full Name
Your answer
15) Comments (optional)
Your answer
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