SpringMettaMeditation Retreat
May30 – June 6, 2018(7nights)
Insight Meditation Center
of Newburyport
West Newbury, MA
Cost: resident sustaining: $980; resident mid-level: $770; resident basic: $630
plus donation (dana) to the staff at the end of the retreat.
Accommodations are in a building a few minutes’ drive from the center. All rooms will be shared with each room and its occupants
sharingone of several bathrooms.
A minimum deposit of $200 is required to register, and full payment is due May16, 2018(two weeks before the start of the retreat).
The deadline to apply for a scholarshipisApril 16. Please note, the scholarship application is a separate form.
By applying to this retreat, you are agreeing to attend the entire retreat and will arrive on the day the retreat opens, Wednesday, May 30, between 3 and 5p.m. You are also agreeing to pay the following cancellation fees:
Before April 18: $25
April18 – May 2: $125
May2– May 16: $200
No refunds afterthe end of the dayon Wednesday, May 16th.
If you are paying electronically, via PayPal, you may complete this form on your computer and email it to
Otherwise, you must print, sign, and mail it.More information is included on the payment form below.
Name: ______
Mailing Address: ______
City: ______State: ______Zip: ______
Phone: ______Work Phone: ______
How do you identify your gender? ______
For room assignments, which best suits your gender? Female____ Male____ All-Gender____
Do you snore loudly? Yes ___ No ___
Email Address: ______(we will use your email for all communications)
Dietary Restrictions - please circle: Dairy-free | Wheat-free | Vegan | Other: ______
Medical Doctor: ______Phone: ______
Contact Person: ______Phone: ______
**Please complete the separate Interview Sheet regarding meditation/retreat history as well as physical and mental health matters**
Payment Form
Registration Fee: resident sustaining: $980; resident mid-level: $770; resident basic: $630
The tuition fee covers administrative costs and food only; none of the tuition fee goes to the ATSB teacher(s) or staff, who generously offer their time for this retreat. There will be an opportunity at the end of the retreat to offer dana (generosity) in the form of an additional contribution to them.
Payment Options:
PayPal—Use the link at againsthestreamboston.org/retreats/ or send payment to
Check—payable to Against the Stream Boston. (Mailing address on last page.)
Amount (PayPal or check): $______.
If sendinga $200 deposit rather than the full amount, you agree to send the rest of the payment (minimum $430) no later than14 days before the start of the retreat. (If you apply for and receive a scholarship, your balance will be reduced by the amount of the award.)
Credit Card (Visa, Mastercard, Discover, and Amex accepted)
I authorize Against the Stream Boston to charge my credit card as follows:
I’d like to pay in full for my retreat now;please charge (circle one):$980$770$630
I would like to pay the minimum deposit of $200 to register, and I authorize Against the Stream Boston to charge thebalance of $______($430 minimum) to my credit card on May 16, 2018(14 days before the start of the retreat). (If you apply for and receive a scholarship, your balance will be reduced by the amount of the award.)
I am applying for a scholarship;I am submittingmyscholarship form along with this registration form.Scholarship applications are due by April 16.
Credit Card number: ______- ______- ______- ______V Code:______Expires: __ __ / __ __
Name as it appears on the card: ______
Billing address: ______
______
Authorized Signature: ______Date : ______
Waiver of Liability
Against the Stream Boston
I acknowledge that I have voluntarily applied to participate in the Spring Insight Meditation Retreat offered by Against the Stream Boston, an affiliate of Against the Stream Buddhist Meditation Society (ATSBMS), from May 30to June 6, 2018, to be held at the Insight Meditation Center of Newburyport located in West Newbury, MA.
I realize that all activities at ATS retreats are voluntary and entirely at my discretion. I am also aware that this retreat will take place in a rural setting and that there may be risks involved moving around the area. I hereby assume all risks of injury to me and my property that may be sustained inconnection with activities undertaken while at this retreat.
I am also aware that this is a silent meditation retreat and participants may experience intense psychological, spiritual, and/or physical states of mind and body arising from the meditation and associated retreat activities. I am voluntarily participating in these activities with full knowledge of the risks involved.
I have read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract between myself and Against the Stream Buddhist Meditation Society.
Name (please print legibly)______
Signature ______Date______
Insight Meditation Center of Newburyport (IMCN)
Waiver of Liability & Authorization for Emergency Medical Treatment
I voluntarily agree to participate in retreat activities at IMCN. I would be willing to participate in a daily mindful work period not longer than 30 minutes per day to support the smooth running of the retreat. If I have any concern about my ability to safely complete a work assignment, I will notify a staff member immediately. I also realize that there are unanticipated risks during such activities. I hereby assume all risks of injury to me and my property, which may be sustained in connection with activities undertaken while at IMCN.
I understand that IMCN is not expected or able to provide medical and/or psychological care. I agree that, in the event a representative of IMCN determines that I need professional medical or psychological attention, IMS has the authority and sole discretion to contact 911 emergency services, as well as the designated emergency contact person listed over.
Any costs incurred for health services are my responsibility and not the responsibility of IMCN.
I understand that I must provide the name and contact details of an emergency contact person in order to attend the retreat, and that I will not be allowed to participate unless I have done so. IMCN will make every effort to communicate with this person in the event of an emergency. This person is someone who can either collect me from IMS or help to make transportation arrangements if I need to leave the retreat early.
I further understand that participation in IMCN programs is at the discretion of the teachers and IMS administration at all times. If, in the opinion of IMCN, I am unable to continue to participate productively in the retreat, I may be asked to leave.
If I am taking prescription medications of any kind and discontinue taking them during the retreat, this will be grounds to be asked to leave.
I have read this agreement and fully understand its contents. I sign it of my own free will. I am of legal age and accept the above disclaimer and authorization.
Your Name (please print legibly) ......
Signature ...... Date ......
Please photograph or scan and email signed forms to
If sending a check please send signed forms with payments to registrar:
ATS Boston Retreat
c/oLia Houk
P.O. Box 409
Henniker, NH03242
Please direct questions to