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.