Registration Form for Washington Street Retreat
October Street Retreat, Washington, D.C. October 13-16, 2022
I'm interested in joining the Street Retreat in Washington, D.C. *
First Name *
Last Name *
Your Answer
Street Address *
City *
State and Zip Code *
Country *
Email Address *
Phone Number *
Date of Birth *
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Emergency Contact Info (please include name, telephone & email address) *
Why does this particular practice appeal to you? AND how did you hear about this retreat? *
Describe your spiritual practice. Do you have a teacher? If so, who? Have you ever done a bearing witness retreat before? If so, where and when? *
Do you have any physical, emotional, or psychological challenges we should be aware of? If so, please list. *
Are you on any medication? If so please list. *
Are you currently working with a psychiatrist or therapist? If yes, please list name and contact info. *
Bread Loaf Mountain Zen Community risk and liability notice:   *
Silver Spring Zendo/One Heart Sangha risk and liability notice:   *
By typing my name below, I acknowledge and understand and do hereby assume full responsibility and expressly release and will hold harmless Bread Loaf Mountain Monastery, Inc., and its agents and associates, and Silver Spring Zendo, Inc., and its agents and associates, from any and all liability which may arise from or in connection with this program. *
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