Apply to Meditate at the Deerhaven Retreat, Winter 2021

Personal Information

Full Name (required)

Full Mailing Address (required)

Phone Number (required)

Email (required)

Date of Birth (YYYY-MM-DD) (required)

Information Regarding your Experience

Courses completed with Sirimangalo (required)
NoneAt-homeFoundationAdvancedInstructor

Meditation History

Health Information

Proof of vaccination

Allergies:

Dietary requirements

Emergency Information

Identification type

Identification number

Who to contact in case of emergency (name, relationship, contact information)

Conditions

Mental Conditions (please check all that apply):
I have been diagnosed with a mental condition.I currently suffer from a mental condition.I have suffered in the past from a mental condition.I am receiving treatment for a mental condition.If you have checked any of the above, please explain:

Addiction to drugs or alcohol (please check all that apply):
I have been diagnosed with an addiction.I currently suffer from an addiction.I have suffered in the past from an addiction.I am receiving treatment for an addiction.If you have checked any of the above, please explain:

Serious medical conditions not covered above (please check all that apply):
I have been diagnosed with a medical condition.I currently suffer from a medical condition.I am receiving treatment for a medical condition.If you have checked any of the above, please explain:

Are you on any medications not mentioned above? If so, which?

Mobility issues or other special needs

You're Almost Done

I have read the SI booklet on how to meditate (required) .http://htm.sirimangalo.org/

I am aware this retreat is located in Florida, U.S.A. (required).

Is there anything else you'd like us to know about you? Do you have any questions or concerns about coming to meditate?

Waiver

I willingly agree to comply with retreat rules, including observation of the 8 precepts as a condition for participation.
I understand that meditation may induce both mental and physical discomfort and, in rare cases, even mental or physical injury up to and including death, and I knowingly and freely assume all such risks, both known and unknown, and assume full responsibility for my participation.
If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the teacher or the members of the board of directors of SIRIMANGALO INTERNATIONAL BUDDHIST MEDITATION SOCIETY INC. immediately.
I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, indemnify, and hold harmless SIRIMANGALO INTERNATIONAL BUDDHIST MEDITATION SOCIETY INC. and its officers, officials, agents and/or employees, other participants, sponsors, advertisers, owners and lessors of premises used to conduct the event (RELEASEES) or others from any and all claims, demands, losses, and liability arising out of or related to any injury, disability, or death I may suffer, or loss or damage to person or property, whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law.

After you submit this form, we will be in touch to confirm your stay.

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