UCLA Mindful Awareness Research Center
Ph: 310-206-7503 Fax: 310-206-4446

Retreatant Form

UCLA Weekend Mindfulness Retreat
Nov 15-17, 2013

Complete form and email to: with subject “Weekend Retreat”

Or Mail to:

Mindful Awareness Research Center (MARC) – Weekend Retreat
Jane & Terry Semel Institute for Neuroscience & Human Behavior at UCLA
760 Westwood Plaza, Room 47-444
Los Angeles, CA 90095-1759.

Which sleeping/room arrangements have you registered for?

·  Single ($580) ______
(bathroom will be shared)

·  Double ($440) ______

·  Commuter ($280) ______

·  Financial Aid ($50) ______
(Financial aid recipients will share a room with 1 or 2 other people).

Please write or type the following clearly

Name ______Date of birth______

Address ______Gender ______

City, State, Zip ______

Email ______Phone ______

EMERGENCY CONTACT DURING RETREAT

Name______Relationship______

Phone ______

CARPOOLING

Do you need a ride TO or FROM the retreat? ____ No ____ Yes [ ] TO [ ] FROM

Can you offer a ride TO the retreat to someone from your area? ____ No ____ Yes

Can offer a ride FROM the retreat to someone from your area? ____ No ____ Yes

ACCOMODATIONS

Most retreatants will be assigned a double room with another retreatant of the same gender. (A limited number of single rooms are available)

Is there a retreatant of the same gender coming to the retreat with whom you have made plans to share a room? Yes/ No ______If so please specify who this person is: ______

Do you snore? Yes / No ______ Do you have insomnia or other sleep disorder? Yes / No______

Do you have any special medical needs? If so, please describe here: ______

Please give any other information that will assist the retreat manager in making room assignments:

______

SPECIAL NEEDS

Please indicate any special dietary requirements you want us to know about?

______

______

Do you have allergies to food or medications? If so please list them.

______

______

If you were to have an allergic reaction, please specify what medications should be taken, and when (e.g. what symptoms would be displayed and what medication should be administered).

______

______

Do you have any medical needs or mobility limitations?

______

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