Silent Retreat Sign-up - Mindful Academy Solterreno

Silent Retreat Sign-up Application Form

Please fill out the form below to apply for the Mindfulness Silent Retreat.

"*" indicates required fields

Personal Details

Name*

Email*

Address*

Phone*

Emergency Contact Phone*

Date of Birth*

Passport / ID Number*

Additional Information

Which Silent retreat dates are you applying for?*

Online or In-person?*

Exact Name you would like on your Certificate*

8-week MBSR Course?*

Have you taken part in an 8-week MBSR or other Mindfulness courses? This is NOT a required prerequisite for acceptance just useful to know

Meditation Retreat?*

Have you attended a Silent Teacher-lead Mindfulness Meditation retreat before? This is NOT a required prerequisite for acceptance just useful to know.

Please tell us a bit about yourself.*

Please tell us a little about yourself, including your current occupation.

How long have you been practising meditation?*

Mental Health?*

Have you had any mental ill-health within the last few years, such as anxiety or depression? If yes please tell us about it here.

Taking Medication?*

If you are taking any medication at present, please say what it is and what it is for.

Life event in the last year?*

Have you had any disturbing life event in the last year, which may make the course difficult for you?

I have read and accept the Terms & Conditions.

I have read and accept the Privacy Policy.

I am happy to share my email with others in the same retreat to help communication within the group.

Comments

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