Southern Insight Meditation: Online Retreat Registration
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Email *
Your Home Address:  Street number and name *
Address: Suburb *
Address: City or Town *
Name *
Contact details: Cell phone; Phone *
What is your Age?
Please outline in detail your background in meditation, if any (number and dates of retreats and name of teacher, type of tradition, years experience). *
Medical History: In order to enable the teacher to provide appropriate guidance and support for you on the gathering, please contact Sarah 027 6693824 if you currently have or in the past have had any of the following. Selecting any category does not mean you will be unable to participate in the retreat. This information is treated as confidential:
$50 is payable to complete your registration.
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Where did you hear about the retreat?
Is there anything else that you think we need to know about?
By submitting this form, I understand that I am making a commitment to the minimum daily participation during the online retreat (as outlined in the email), and to follow the retreat guidelines and the instruction of the teacher(s). I understand my participation in this online retreat is undertaken and continued with the agreement of the teachers.
Name, date and signature
Please now click "submit" below and complete the security questions that come up to check that you are not a robot.      You should receive a summary of the answers that you have given us in your email box.  If this does NOT happen then please contact us (it may mean that your registration has not gone through)
A copy of your responses will be emailed to the address you provided.
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