World Dharma Training Retreat Australia 2017
Online Request To Attend – Application Form
Wisdom of Mindfulness May 29 – June 4, 2017

Kindly fill out all fields in the application and we will get back to you shortly

Sex?  Male Female

Full Name (First, Middle, Last)





Zip/ Postal:

Telephone (mobile) for texting:




Skype contact

Best days and times to reach you:



Emergency Contact Name, Relationship to You

Contact Address (City, State, ZIP & Country)

Emergency Contact Phone & Email

How did you learn of this retreat?

Please list meditation retreats you've attended in the past. Include: Date, Teacher, Location, and length.

If you have attended any previous retreats with Alan, please list them.

Please explain in a sentence or two why you want to attend this retreat.

What (if any) psychological and mental health issues have you had in your life, past or present?

Please list any medication you are currently taking for these issues.

Please list any dietary restrictions that are essential for you during the retreat.

Do you have any special needs or concerns that we should be aware of?

How will you pay for the retreat? Pay Pal? Credit Card? Check? Other?

Upon acceptance to attend the 7-day retreat a ​$195 ​deposit must be made, with full payment by ​March 15 (60 days before the start of the retreat), unless otherwise agreed. Please note, due to the non-profit nature of this retreat, i​f possible, i​t would be ​really ​helpful if you could offer ​your full retreat fee at ​anytime prior to the deadline. ​We're producing this on a shoe-string and further, limiting attendance to keep it intimate. ​
Thank you kindly.

On the other hand, if you​r​ ​circumstances are such that you would like to explore a creative personal payment plan other than what is presented, ​it is our intention to do everything possible to support everyone who sincerely wants to ​attend the retreat. Be sure to fill out the best plan for you​ in the field below. In addition, a monthly payment amount can be arranged, if required.​ In other words, we're here to support you as best as we can and thank you for supporting us in the smooth creation of this special retreat.​

We look forward to ​meeting you soon, as do our ​wonderful ​partners ​at Gymea Eco Retreat & Spa​ and our amazing Goddess caterers​.

Please check the appropriate box, below:
 Although I can pay my deposit upon acceptance to the retreat I wish to explore a creative payment plan I do not need a special payment plan and am prepared to offer my deposit upon acceptance to this retreat

If you need a creative plan, please tell us the amount you wish to pay, your ​payment ​plan, and the method of payment, below.