Treasure Buddhist Sangha DharmaTreasure.org Instructions:   Thank you for your interest in one of our retreats! We look forward to having you attend.  Please fill out this form and submit it electronically (use the "submit" button at the bottom of the page).  Thank you.

	1. Please enter your contact information below.
	Name(s) Phone Address City State AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NF NH NJ NM NS NT NU NV NY OH OK ON OR PA PE PQ RI SC SD SK TN TX UT VA VT WA WI WV WY YT Zip Email Address

	2. Have you meditated before?
	yes no

	3. What are your current daily or weekly spiritual practices (frequency, duration, and type of practice):

	4. If you have meditated, how long (months or years) have you been regularly practicing meditation?

	5. Please provide dates and teachers and styles of previous retreats you have attended.

	6. List style of practice, duration, and locations of any intensive meditation practice in self-retreats:

	Please answer all questions. You will not be denied the opportunity to attend the retreat due to your responses to these questions, but we may need to ask for additional information or discuss special arrangements.   Please note:   ·       The retreat is a silent environment. Long-term retreatants need to be at ease with both silence and solitude. ·       There will be no opportunity to leave the retreat site for routine medical treatment or procedures and we will not be able to fill prescriptions for you. ·       We offer a simple, balanced vegetarian diet. Our capacity to accommodate customized diets is limited. You will need to make arrangements in advance to meet any special dietary requirements.

	7. Have you ever been diagnosed with a psychological condition or mental illness? If so, please describe:

	8.  Do you have any history of physical illness or limitations that might be aggravated by or interfere with sitting and walking meditation? If so, please explain and describe any special needs you have:

	9. Do you have any physical limitations that would prevent you from participating in the daily work period?  If so, please describe:

	10. Please review the Practice Guidelines (a separate document) thoroughly. If you have any questions relating to the retreat and Practice Guidelines, or any other aspect of the retreat, please ask them here:

	Thank You!