Online registration is OPEN for this retreat
Welcome to the registration for the 2014 Buddha Path Urban Spring Retreat ~ Salt Lake City, led by Upasaka Bodhisattva Sean D. Young.

If other members of your family or circle of friends plan to attend, each person should fill-out and submit this application as soon as possible. Your privacy is important to us. This information will not be conveyed to any third party outside of the Dzogchen Shri Singha organizations.
Sign in to Google to save your progress. Learn more
Age Group *
Select Your Age Group with Corresponding Fee:
First Name *
Your personal name.
Last Name *
Your family name.
Street *
Street address or post office box.
Unit
Apartment, suite or unit number.
City *
State *
State or province.
ZIP *
ZIP or postal code.
Country *
Nation or country.
Email *
Phone
Please enter your cell or another telephone number where we can reach you prior to the retreat.
Family Contact
Provide the name of at least one family member or friend who won't be attending the retreat, along with their phone numbers, in case of emergency.
About the Medical Questions that Follow

For the safety of yourself and others, and in case of medical emergency, please respond to the following important health questions.

The retreat organizers aspire to maintain a healthy and safe environment for all retreatants. However, each individual is responsible for his or her health care during the retreat. This includes having an adequate supply of prescription medications, using them as prescribed and immediately reporting to the retreat director any health issues as they arise during the retreat.

Any misuse of prescription or over-the-counter drugs, or any possession or use of illicit drugs, alcohol or tobacco will not be tolerated. There is no smoking anywhere on the property. Violators will be dismissed immediately.

The information gathered in the three questions below will be kept confidential and will only be used to provide the retreat staff with the knowledge to appropriately respond in the event of an emergency.
Addiction Recovery
Have you ever been, or are you currently, in recovery or rehabilitation for addiction to alcohol, drugs, or any other substances? If so, list the recovery program type and explain your current status.
Health Issues *
Do you have any health issues that will require ongoing maintenance or special health care during the retreat, for example related to: life threatening allergies, chronic physical or mental health conditions, heart conditions, blood pressure, thyroid, insulin, wheelchair access, etc. Please briefly explain all significant conditions and ongoing treatments.
Medications
Please indicate if you currently on any prescription medications, and if so, list the medications.
Physician Contact
Please list your primary physician's name and phone numbers in case of a medical emergency.
Congratulations, you are nearly done!
Most of the remaining questions are optional. However, please answer as many as possible to help us plan the retreat and better serve you.
Prior Retreats
Have you previously attended one or more Dzogchen Lineage retreats with Dzogchen Khenpo Choga Rinpoche? This is not a requirement to attend this retreat.
Clear selection
Retreats Attended
If you answered "yes" to the previous question, then please note one or more of the retreats you attended that were guided by Khenpo Choga.
Accomodations *
Please tell us your preferred accommodations during the retreat.
Special Needs
Describe any other special needs you have or enter any comments you’d like the organizers to read.
How Learned?
Please let us know all the ways you learned of this retreat (for example: via an email newsletter, announcement at Buddha Path Practice, saw an online ad, found out through a web search, etc.).
Pledge
Please consider contributing to the Retreat Fund that will make possible purchase of supplies for the retreat and scholarships to pay the retreat fees for people in need. Your contribution will generate great merit for you and help accomplish our goal of decreasing and eliminating negativity for the benefit of all beings. Include this donation when you pay your retreat fees. Your fee payment is not tax deductible, but your donation to this fund is tax deductible to the full extent of the law. Please enter the $ U.S. dollar amount you wish to pledge:
Questions
If you have any other questions or comments for the Internship Director, you may enter them below and we will respond to them within the registration web site. We may also contact you by phone or email to answer any urgent or specific questions. The organizers are unpaid volunteers, so your patience with us is much appreciated!
Refuge Vows? *
Have you ever formally taken refuge vows with a qualified Buddhist teacher?
Who gave vows?
If you answered Yes to the question above about taking refuge, who first gave you the vows?
When took vows?
If you answered Yes to the question above about taking refuge, what year did you first take your vows?
Agreement *
I have read the Overview and Details pages of the registration website and undersand all of the conditions and policies for this retreat.
Please click the "Submit" button below to send us your responses.
Carefully review your answers above, make a note your total fees due adding any pledge you may have made, and then click the Submit button below to record your registration and be taken to the Payment Options page.
May all beings benefit!
Submit
Clear form
Never submit passwords through Google Forms.
GoogleForms
This content is neither created nor endorsed by Google.