SOUTHERN INSIGHT MEDITATION DHARMA GATHERING  Fri 8th January 2015- Friday 15th January 2015)
REGISTRATION FORM - (CLOSING DATE FOR REGISTRATION IS 23RD DEC 2015)

Your Name		Age		
Address			Occupation		
		Phone No		
		E-mail		
What dates are you planning to attend?	Fri-Sun ;  (2 days)
Fri to Tues (4 days) 
Fri to Fri (7 days)	

Are you bringing children (delete as appropriate)?   Yes /  No   

If so,  how many ?

Please write their age(s) here:  

Please outline in detail your background in meditation, if any (no./dates of retreats + name of teacher, type of tradition, years of experience).  

Medical History:  To enable the teacher to support you on the retreat, the following information is required.  Answering ‘Yes’ to any category does not mean you will be unable to participate in the retreat.  This information is treated as confidential.

Please cross the appropriate box FOR EVERY CONDITION

	Yes	No	
Cancer
Alcohol or Drug Dependency
History of Psychiatric Illness
Heart Disease
Any Long Term Chronic Illness	Yes	No	
Asthma							
Chronic Fatigue						
Eating Disorder						
Mild/ Severe Depression						
Recent Major Surgery						

Other:  Please specify				

Transport
I would like a ride to/from the retreat		
I can offer a ride to/from the retreat		
If yes, how many people can you take?		
What suburb do you live in?

Food on retreat is vegetarian, with a vegan option (please indicate below).  For practical reasons any other diets cannot be catered for unless medically required.

Please outline any other special needs?

Payment

Amount of Deposit ______________(minimum of $50 per adult)

Please tick method of payment
☐ Cheque; 
☐Online banking - Kiwibank:  38-9017-0230890-04. Ref:  CODE; your name; # of people
PLEASE NOTE this is a new account number!  
☐Cash

The balance is payable when you arrive at the retreat, or can be payed online (please pay at least 2 days prior to the retreat start date if this is your preferred way of paying).  

The fee covers all meals, facility hire, tent hire, teacher travel expenses, and admin costs.  A subsidised rate is also offered for those on low incomes.  If you are able to, we ask that you pay the full amount, which is the actual cost of the Gathering.  If your financial circumstances preclude this, please discuss this with a SIM committee member and pay the maximum amount you are able to.  Southern Insight will subsidise your retreat by the remainder.  
  Please tick if you will need to pay less than the full cost.

Name of Contact person in case of emergency on retreat: _______________________________

Their phone no.:_________________

Where did you hear about the retreat? ________________________________________________

 Please tick if you do not want your name and address to be passed on to similar organisations.

All other information given on this form is completely confidential.

I agree to take full responsibility for myself (and my children) during the retreat and to follow the retreat guidelines and the instruction of the teacher.  I understand that this retreat is undertaken and continued with the agreement of the teacher(s).

Signed:  _____________________________	Date:  ______________

If you cannot download, sign and scan this form, you will need to sign it on arrival at the retreat.

Please email this completed form to southern.insight.meditation@gmail.com  or post to Chrys Horn, 264 Kennedys Bush Rd, Kennedys Bush, Christchurch 8025