Southern Insight Meditation: Dharma Gathering Registration

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This is a 5 day event from Friday 5.00pm, January 20th 2023 - Wednesday 2.00pm, January 25th. The Gathering will not include young children, as we have in previous years, due to the complexities of managing events in Covid times. For the same reason, numbers will be limited to 40 people

Email *

Name *

Age (in years)
*

Gender
*

What is your street address and SUBURB?
*

What town, city or region do you live in? What is your Post Code?
*

Contact details: What is your Cell phone and or Phone number
*

Please provide a detailed outline of your background in meditation, if any (number and dates of retreats and name of teacher, type of tradition, years experience). *

System of payment for $50 deposit (full cost $295)

Online Banking: Southern Insight Meditation, Kiwibank 38-9017-0230890-04, Please include DG2023 as code and name with payment

Bank Deposit at any branch of Kiwibank into our account with the ref details above

Clear selection

Medical History: To enable the teacher to provide appropriate guidance and support for you on the gathering, please contact Sarah 027 6693824 if you currently have, or in the past have had, any of the following. Selecting any category does not mean you will be unable to participate in the retreat. This information is treated as confidential:

Asthma

Alcohol or drug dependency

Mild or severe depression

Recent major surgery

Cancer

Eating disorder

Heart Disease

Chronic fatigue

History of psychiatric illness

Any long term chronic illness

Is there anything else you think we should know about you, eg any special needs (other than dietary ones)?

Do you require transport to/from the gathering? *

Yes

Can you offer someone a ride to/from the gathering? *

Yes

Food on the gathering is vegetarian, with a vegan option. For practical reasons, any other diets cannot be catered for unless medically required. Please indicate your preference:

Vegan option

Vegetarian option

Please let us know any medically required special dietary needs here.

The fee of $295 covers all meals, facility hire, the teacher’s travel expenses, and admin costs. If you are able to, we ask that you pay the full amount, which is the actual cost of your gathering. If your financial circumstances preclude this, please pay between 70% - 100% of cost and Southern Insight will subsidise your gathering by the remainder. The balance is payable when you arrive at the gathering. Please indicate if you will need to pay less than the full cost, and the amount you are able to pay: *

I can pay the full cost

I need to pay less than the full cost

Other:

Required

If you cannot pay the full cost, please indicate how much you will pay.

Contact person and phone number in case of emergency: *

Where did you hear about the gathering?

By submitting this form, I agree to take full responsibility for myself during the gathering and to follow the gathering guidelines and the instruction of the teacher. I understand that this gathering is undertaken and continued with the agreement of the teacher(s)

Name, date and signature

Please now click "submit" below and complete the security questions that come up to check that you are not a robot. You should receive a summary of the answers that you have given us in your email box. If this does NOT happen then please contact us (it may mean that your registration has not gone through)

A copy of your responses will be emailed to the address you provided.

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