Dedicated Practitioner Program (DPPT26)

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1 Welcome

4 Practitioner Details

Phone *
Address line 1 *
Address line 2
City *
State/Province *	This list includes US and Canada, States/Provinces. For all other countries, please select "Other" at the end of this list and then select your country below.
Zip/postal code *
Country *
Birth date *	We ask this for validating your account, for emergency purposes, and rooming for residential retreats. We do not share this information outside of our organization.
Meditation Practice Experience-ResRetreats *	New to Vipassana residential retreat practice. I've attended 1-3 residential retreats. I've attended 4-10 residential retreats. I've attended 10+ residential retreats.
Emergency contact name *	Please include the name of someone who will be available during your retreat/program. For Residential retreats, if you are traveling from a foreign country, we would prefer that you provide a contact person who is in the United States.
Emergency contact relationship *
Emergency contact phone *	Please include the best number to reach your emergency contact person while you are on retreat or participating in our program. This will not be used for anything except to care for you in case of an unexpected crisis or emergency.
Liability Waiver for Participating in On-Land Programs - By checking this box *	I AGREE - I acknowledge that I have read and agree to the terms in this "Liability Waiver"PLEASE READ - LIABILITY WAIVER

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5 Demographics

Current age *
Gender *
How do you self-identify your gender?
Do you self-identify as BIPOC? *	Yes-BIPOC No-BIPOC Decline to state-BIPOC
Describe your ethnic origin or background *	Type N/A, if decline to state.
Do you self-identify as LGBTQIA+? *	Yes-LGBTQIA+ No-LGBTQIA+ Decline to state-LGBTQIA+
How would you describe your sexual orientation?	Optional.

6 Accommodations and Food

All attendees should be prepared for the possibility they will be in a shared accommodation and to "accept what is offered" in the spirit of the Buddhist precepts. We have more single rooms than double rooms; however, due to the high number of single-room requests, we cannot honor all requests. Single-room priority is reserved for those with serious medical needs plus a limited number are also reserved for those selecting the Supporter rate which guarantees a single room, if that rate is available. All remaining rooms will be randomly assigned. We gratefully welcome room-share requests!

Room Assignment Acknowledgement - By checking this box *	I AGREE - In the spirit of the precept of "taking what is offered" I acknowledge and understand that I may be assigned a double or a single room; unless I have selected the Supporter rate which guarantees a single room.
Preferred gender floor *	No preference All-gender floor Female only floor Male only floor We cannot guarantee we can accommodate all "floor preferences" but we will do our best!
Requested roommate	Type the name of the person you want to share a room with. Roommates MUST request each other. Please do not fill in with any other room accommodation requests.
First-floor room needed?	Yes, I have mobility limitations.Only select if you MUST be on a first-floor room. We prioritize first-floor rooms for those with mobility limitations and elders in need.
Describe any serious mobility/physical limits we should be aware of	This includes: if you use a personal wheelchair and/or if you have an ADA certified service dog; if you are DEAF, or have severe Blindness. We would like to connect with you as soon as possible to see how we can support your participation.
Need scooter	Yes, I need to reserve a scooter.We have a maximum of four scooters available per retreat. If you have a serious mobility issue, we recommend that you reserve a scooter.
Chemical sensitivity	Yes, I need to be in a chemically sensitive building.We have one dormitory that has wood flooring and no carpeting throughout the building. If you have allergies or are a chemically sensitive being, we recommend this building for you.
Snore *	No, I don't snore Yes, I snore
Allergies *	No food allergies Yes food allergies FOOD ALLERGIES Spirit Rock serves lacto-ovo-vegetarian meals. We cook with seasonal, organic products whenever possible and source from local farmers and other suppliers for the freshest ingredients available. We have a 'simple foods' table available for those with particular food limitations and every food dish is labeled with the ingredients used so you may use your own discretion. You’ll have an opportunity to let the cooks know about your particular food needs. If 'YES', PLEASE TELL US WHAT THE FOOD ALLERGY IS AND THE LEVEL OF SEVERITY.
What is your food allergy and level of severity?*	*We are NOT able to accommodate extreme dietary preferences. However, if you have a LIFE-THREATENING ALLERGY (eg. peanut) we should have a conversation with you before you attend a retreat here. Please contact the Registration Department as soon as possible.
Dietary Retrictions	Vegan Gluten Free Check all that apply.

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7 Tell Us More

New to Spirit Rock? *	Yes-new to Spirit Rock No-not new to Spirit Rock
How did you hear about Spirit Rock?
May we share your contact information with the teacher(s) or presenter? *	Yes No
Image Consent	I AGREE - I acknowledge that I have read and agree to the terms in this "Image Consent"PLEASE READ - IMAGE CONSENT: I grant permission to Spirit Rock Meditation Center to take photographs and/or record digital media of me for use in promotional materials. These materials might include printed or digital products. I authorize the use of these images and recordings without compensation to me. All images and recordings shall be the property of Spirit Rock.

8 Payment

Credit Card Fee (non-refundable)	Credit Card Fee Opt-in I agree to cover the credit card processing fees for my registration. I understand that this fee is non-refundable if I should cancel my registration.
3% Credit Card Fee (non-refundable)	$0

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1 Welcome

2 Price

Select an option*

Supporter DTP.

Benefactor DTP.

Sustainer DTP.

Basic DTP.

Scholarship Rate 1 DTP.

Mudita/Karuna Scholarship Rate DTP.

BIPOC Scholarship Rate DTP.

Benefactor

Sustainer

Online Base

Online Reduced

Mudita/Karuna Scholarship

People of Color Scholarship

3 Additional Programs

Participants

4 Practitioner Details

5 Demographics

6 Accommodations and Food

7 Tell Us More

8 Payment