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 in planning the meals and accommodation

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

Gender
MaleFemale

Age

Food allergies or special dietary needs
Please list any food allergies or special dietary needs that we should be aware of.

Physical disabilities
Please list any physical disabilities we need to be aware of (for purposes of getting around, eating, sleeping).

Medical
Please list any relevant medical conditions(diabetes,epilepsy,etc..) that it would be helpful for us to know about.

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 Name

Relationship to you

Number of years practising meditation if any

Approx. number of retreats attended if any

More details of retreats attended (if any) (Where, length, what tradition etc..)

Name of event/retreat registering for

If driving to retreat are you prepared to offer a lift

YesNo

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.