Your full name (required)

    Your contact number (required)

    Your email (required)

    Your address

    ALL INFORMATION IS CONFIDENTIAL and will be deleted once the retreat has finished. This information is helpful for the teacher leading the retreat and for the retreat managers

    PLEASE FILL IN ALL FIELDS AND USE AS MUCH SPACE AS IS NECESSARY. Type N/A if particular question in not applicable.

    Psychological concerns
    Please list any mental health problems (such as depression, panic attacks, schizophrenia) that would be helpful for us to know about.If you wish to discuss this in confidence before applying for the retreat please call Sunyata at 061-367073

    Medication
    If you are currently taking any kind of medication that we should be made aware of, please enter details.

    General well-being
    Do you have any relevant factors that you would like the teacher to know about - such as a recent bereavement, family difficulties, suicidal thoughts, panic attacks, history of abuse, stress,etc. If you wish to discuss this in confidence before applying for the retreat please call Sunyata at 061-367073

    Coming on retreat
    Why are you coming on this retreat?

    Emergency Contact Info

    Emergency contact name

    Contact number of emergency contact

    Relationship to you

    Number of years practising meditation if any

    Approx. number of retreats attended if any

    Name of event/retreat registering for

    We ask that all participants commit to attending the entire retreat. If for any reason you are unable to do so, please consult management before the retreat.
    If you need to cancel please let us know asap so that your place can be allocated to someone else. Thank you.