Street Retreat San Francisco
November, 16-20, 2019
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First Name *
Last Name *
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:
Bread Loaf Mountain Monastery, Inc., and its staff and representatives are acting as agents and will not be held liable for anything beyond their control. Bread Loaf Mountain Monastery reserves the right to accept or reject any person as a trip member at any time. Participants will assume the responsibility to be in good health and physical condition before the departure date, and are responsible for reviewing all information.

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 from any and all liability which may arise from or in connection with this program. *
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