Application Form
A Dharma Gathering

28th November to 2nd December 2012

Personal Details:

Name: / Gender: / Age:
Address:
Email:
Phone: / Mobile: / Home:

Contact person in case of emergency during the retreat:

Name / Relationship / Phone contacts

Please indicate if you have any of the following dietary requirements:

Vegan: / Gluten free: / Dairy Free:

For other special dietary requirements you will need to make your own arrangements

Please enter your attendance and fee details:

Full time / Daily / Days attending / Total Fee
Cabin Accommodation / $250 / N/A
Dormitory Accommodation / $200 / $60
Off-site Campers and daily visitors / $160 / $45

Definition: A day is calculated as 24 hours with one overnight sleep three meals

If you are not attending the whole Dharma Gathering (the full week), please indicate arrival and
departure days and times:

Arrival – Day & Time / Departure – Day & Time

How will you be paying?If paying by EFT don’t forget to use ‘DG’ plus your name as the reference.

Cheque/ Money order / Cash / EFT / Reference Name - (DG & your name)
$
Deposit/Full payment / $
Deposit/Full payment / $
Deposit/Full payment

Please note – At the Dharma Gatheringthere are no EFTPOS facilities so please bring cash or cheque

How did you hear about this event ? / Teacher  Friend  Website  Flyer  Email  Newsletter 
Other: ……………………………………………………………….

Transport to & from Yarrahapinni:

Car registration if parking atYarrahapinni:

If you can offer a lift, please say from where and the number of people you can take:

I can offer a lift from: / Number of people:

If you would like a lift, please say from where:

I would like a lift from:

The following information will be treated confidentially:

If you have a current medical or first aid qualification and would be willing to assist in an emergency please indicate your qualification:

If you have any health condition(s) that could be problematic whilst attending the Dharma Gathering please make us aware of this by briefly describing your condition below:

During retreats some people may experience intense or unusual psychological, spiritual or physical states of mind/body. Retreats may not be suitable for people with some psychological conditions.

Do you have a history of psychosis, a current major depression, current drug/alcohol problem or other psychiatric condition? / Yes/No / Briefly describe

By printing/signing my name below, I confirm that the above information is correct.

I will inform the teachers/managers if my circumstances change before or during the Dharma Gathering.

Name orSignature:______

Date: ______

* Don’t forget to print out the ‘DG information’ for full Dharma Gathering details *

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