Registration Form for Retreats Today’s date ___________________

Name (Last, first): __________________________ Daytime phone: ________________________

Dharma Name: ____________________________ Other phone: __________________________

Address: ______________________________________________ Birthday: ___________

City/State/Zip: _________________________________________________

Email: ______________________________________ Gender: Female _____ Male _____

How did you come to know about us? (please check all that apply)

A student from here ____ Family or friends (non-students) ____ Book ____ Website ____ Pal talk _____

Newsletter or Calendar_____ Radio____ Video____ Other (please explain) ____________________

Why are you interested to come here?

Please list any significant medical and/or mental conditions:

Are you seeing a therapist or counselor? _____ If so, why?

Do you have any meditation experience? If so, what type, the teacher’s name

and for how long have you been practicing?

Travel plans and Retreat cost

Arrival date and time: Departure Date and time:________________

Number of nights stay at the Center: _______ x $50 per night = ______________ total cost

Please enclose the minimum deposit (50%) of the total cost and return it as soon as possible.

This will reserve a space for you. We are a small Center and the number of students is limited.

The payment balance must be received two weeks before your retreat begins. There are no refunds after that date. Checks can be made payable to: Universal Door Meditation Center.