MAM Retreat Registration Form

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*Retreats are open to individuals ages 18 years or older.

Email *

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Name: *

Address: *

Phone number: *

Emergency contact name and phone number: *

How did you hear about this retreat? *

Please describe your current mindfulness practice including previous retreat experience: *

Please describe any psychological conditions that might make retreat practice challenging at this time(such as grief, recent loss, suicide thoughts, addictions, psychiatric diagnoses, etc.). If you are experiencing intense emotional states, please check with a therapist to determine if this is an appropriate time to undertake silent retreat. We recommend that only participants who are experiencing a reasonable degree of emotional stability consider longer silent retreats. *

Do you have any medical needs, injuries, illnesses, or physical or mobility limitations that might impact your retreat experience or require special accommodations? If so please describe: *

We will be maintaining a retreat environment that invites periods of silence. Contact with the outside world is minimal. Retreatants need to be able to tolerate silence and solitude, remain in the retreat environment throughout and refrain from cell and smartphone use, texting, e-mail, or other forms of communication (except as needed in their household, or in case of emergency). Do you have any concerns that this type of environment might be problematic for you? If yes, please explain: *

Is there anything else you would like the teacher(s) to know that might help them guide your practice during this retreat? *

If you are attending the retreat on-site, do you have any dietary restrictions we should know about (vegetarian, vegan, gluten free, dairy free, nut allergy, etc)? *

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