Tallowwood Sangha Incorporated

Application Form
Mindfulness, Insight & Liberation Retreat
3rd to 9th December 2017

Section 1:

Personal Details:

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

Contact person in case of emergency during the retreat:

Name / Relationship / Phone contact

Personal Requirements:

Dietary: / Vegan - q / Gluten free - q / Dairy Free - q
Do you have sleep issues that may disturb others?
Other needs:
If you have a current medical or first aid qualification and would
be willing to assist in an emergency please indicate your qualification:

Transport to and from Sangsurya:

Car details if parking at Sangsurya: / Make: / Rego:

If you can offer a lift, please say how many 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:

Note: Reasonable attempts will be made to meet special requirements & lift requests but cannot be guaranteed

¯ The full fee for this event is: $680 - The deposit amount is: $180 ¯

Payment Methods:

1) Electronic Funds Transfer (EFT) to Bananacoast Community Credit Union (BCU):

BSB: 533 000 Account Name: Tallowwood Sangha Inc. Account Number: 179921

Remember: If paying by EFT use ‘CTRN’ plus your name as reference to ensure your payment is linked to your booking

OR …..

2) Cheque/money order paid to ‘Tallowwood Sangha’ & post to:‘CTRN Retreat 2017’; 20 Bielsdown St, Dorrigo 2453

How will you be paying? / Electronic Funds Transfer r / Cheque r / Money order r
How did you hear about this event ? / Teacher r Friend r Website r Flyer r Email r Other: ……………….
Would you like to be emailed about future insight retreats ? Yes r No r

Section 2: Confidential Participant Information

* By completing this section you are providing background information for teachers only

Name: / Gender: / Age:

Life situation and/or occupation:

What is your Current Meditation Practice (if any):

Previous Retreat Experience in the Insight Vipassana tradition: Beginner - (no previous experience): r

Some - (attended less than five retreats): r Experienced – (attended more than five retreats): r

Please list any retreats you have attended in the past five years:

Tradition / Teacher / Duration

Briefly describe any current Issues that may make meditation difficult for you at this time:

Physical
Mental / Emotional
Spiritual

Many meditators are on a healing journey. On meditation retreats individuals may experience strong physical and psychological states. Please answer all the following questions so we can care for you appropriately.

Do you have any current or previous: / Yes/No / Past / Current
Drug (including alcohol) abuse or addiction issues
Diagnosis or treatment of a mental illness (psychological or psychiatric)
Medical conditions that could require attention during the retreat
If you answered “Yes” above please give further information about your conditions: / Yes / No
Are your symptoms currently well controlled?
Do you currently drink alcohol on a regular basis?
¯  If so, have you ever had any problems abruptly stopping alcohol usage?
Do you currently use recreational drugs e.g. marijuana, amphetamine, ecstasy?
¯  If so, are you able to abstain from all recreational drugs during your retreat?
Have you ever made a serious attempt at taking your life?
Do you have a history of emotional instability during intensive meditation retreats?
¯  If so, please briefly explain:
Do you have any condition that might interfere with sitting and walking meditation?
Do you have any limitations that prevent you from participating in the daily work period?

If you are taking any prescription medications for physical or psychological conditions please list below each medication and daily dosage, as well as the condition it is being used to treat:

Condition / Current Effect
on Daily Life / Treatment
Including medications / Hospital admissions / Current Doctors or Therapists – Name, address, contact number

Do you give Management permission to contact your Doctor/Therapist in an emergency? Yes r No r

By printing/signing my name below, I confirm that the above information is correct. I will inform the teachers/managers of any change in my circumstances.

Name or Signature: Date:

·  Don’t forget to print out the ‘Retreat information’ for full details *

** This is a Tallowwood Sangha Incorporated Event **

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Mindfulness, Insight Meditation & Liberation Retreat – 3rd to 9th December 2017 – Application Form