Future Retreat Registration

Sex? MaleFemale

Full Name (First, Middle, Last)

New MexicoMaui, HawaiiCosta RicaPortugalNew ZealandBali

Would you be willing to assist us in the organization of the retreat in the location you checked? If so, please let us know what you would like to do to assist, ie promotion, cook, admin, etc etc. ​

I would like to organize a World Dharma Retreat​ in a location not mentioned, above​? If yes, please let us know the location you had in mind: City, Region, Country. ​

Would you be willing to assist us in the organization of the retreat in the location you checked? If so, please let us know what you would like to do to assist, ie promotion, cook, admin, etc etc. ​

Have you organized a retreat before?
If so, please explain when, where, how long, what type of retreat and for whom. ​

Address

City

State/Provence/Territory

Country

Zip/ Postal:

Telephone (mobile) for texting:

Email

Website

Facebook

Skype contact

Best days and times to reach you:

Nationality:

Occupation

Emergency Contact Name, Relationship to You

Contact Address (City, State, ZIP & Country)

Emergency Contact Phone & Email

How did you learn of World Dharma and Alan Clements?

Please list ​any significant ​meditation​/dharma​ retreats you've attended. Include: Date, Teacher, Location, 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? Pay PalCredit CardCheckOther

I hereby certify that all of the information contained in this application is complete and accurate to the best of my knowledge. I understand that, if accepted, omissions or false statements on this application shall be considered sufficient cause for dismissal. I will not hold World Dharma, the Buddha Sasana Foundation, or the owner of the Retreat facility responsible for any liability during my travel or stay at this retreat.

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