4 Days unscheduled retreat
June 27-30, 2020
Full name
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First Name
Last Name
Date of birth
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Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email
*
example@example.com
Country and time zone where you will be during the retreat
How did you find out about this retreat?
Have you practiced meditation before? (click all that apply):
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on your own
with the help of books or recordings
with a teacher or friend
on a retreat
Other
If you have meditated before, please describe--which style of meditation, book, recording, technique, teacher and/or personal experiences have been helpful? If you haven't meditated before, what interests you about meditation now?
Previous retreats with Jaya -- when, where, how many days and any comments you would like to share about your retreat experience:
Do you have any past or present sleep or eating issues, abuse history or issues, suicidal thoughts or other psychological imbalances? (If yes, please give details of occurrences, treatment and medications if any.)
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Is there anything else that you like Jaya to know about you, or your life, or your practice for this retreat?
To register for this retreat you need to agree that you are over 18 years of age and fully responsible for your mental and physical health.
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I Agree
"I commit to keep all communications from the course confidential: I will not share course materials nor the sharing of other participants with anyone else."
*
I commit
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