Application for Being Blessed by the Land of Vallecitos: Gently Held Self-Retreat 
*Application Instructions*
For those interested in attending self-retreat at Vallecitos, please fill out the following application. We will email you to let you know the status of your application within 14 business days. Once the retreat is full, approved applications automatically join the waiting list. If a space opens up and you are invited to attend, we will email you with a registration link to sign up for the retreat. Accommodations will be offered on a first-come first-served basis. We encourage you to apply early as we expect that accommodations will go quickly. 

Your privacy is a priority. All responses will be kept confidential.
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Email *
Your First Name *
Your Last Name *
Your Pronouns
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Your City, State/Province, Country *
Phone Number *
Year of Birth (Optional - this helps us with housing assignments)
Have you been to Vallecitos before? *
Are you coming on your own or with others? If others, please list their names.
This offering is eligible for those who have attended at least one residential meditation retreat. Please list a few of the most recent retreats you attended and the retreat teachers. *
Do you have a current meditation practice? If yes, please describe. *
What motivates you to come to Vallecitos at this time?
Do you have any physical limitations that would prevent you from participating in the daily work period? If yes, please explain.
Do you have any history of physical illness or limitations that might be aggravated by or interfere with your time at Vallecitos?  It is very important to your well-being that we have this full information. *
Are you currently being supported for your psychological well-being? Are there psychological conditions that you feel are important for us to know about to better understand your needs regarding your time at Vallecitos? *
Are there recent circumstances in your life (e.g. loss of a loved one, illness, substance abuse, prolonged depression, relationship problems,) or past history (e.g. serious attempt to take your life) that might impact your time at Vallecitos? If yes, please explain. *
Are you currently taking medications? If yes, please list medications, dosage and for what purpose.
Are you currently seeing a therapist or counselor? If yes, please provide therapists name and contact number.
A copy of your responses will be emailed to the address you provided.
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