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Grief as a Change Agent - Lottery Application

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1 Welcome

3 Practitioner Details

Phone *
Preferred or Chosen Name	We want to be respectful in addressing you. Complete, if different from legal name. Leave blank, if not.
What are your pronouns? *
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.
Country *
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.
How long are you able to wait for a spot?	Enter the absolute last date and time you are able to accept a spot in the retreat/program. We will not contact you after the date you list.
Do you anticipate needing a scholarship rate? *	No, I do not need a scholarship rate. Yes, I will need a scholarship rate. Now is the time to make your request known. We often have a greater need than we have scholarship funding to offer, so we cannot guarantee being able to fulfill all requests.
What sliding scale rate do you intend to choose? *	Please consider paying at the highest rate that you can afford: your generosity supports Spirit Rock, staff, and your fellow practitioners. Any amount offered above the Sustainer rate is a tax deductible donation to Spirit Rock, and your generosity will enable and support the participation of others. These fees do not include dana for the teachers.
Have you received a scholarship for two or more residential retreats in the current calendar year? *	Yes No Gentle Reminder: Scholarships are limited to TWO per calendar year for on-land (residential) retreats. To create as much access to our residential retreats, we ask that you abide by the limit above. Scholarships received from participation in extended training programs or any short duration online programming, is excluded from this limit.
Commuter Prerequisite (Please Read):	PREREQUISITE APPLIES TO COMMUTERS ONLY To be accepted as a Commuter, you must have attended at least one 7-night or two 5-night silent, Insight (vipassanā) meditation residential retreats PRIOR to this retreat. These retreats should have been silent meditation retreats led by Spirit Rock, IMS, or IRC teachers, or other recognized Insight Meditation teachers. The retreats should have had a similar format to this retreat, with instructions, practices and talks focused on Insight Meditation.
Commuter Prerequisite Acknowledgment: *	Yes, I am interested and meet the prerequisite for Retreat Commuter (& when applicable, the prerequisite for a residential spot) No, I am only interested in a Residential Spot
List eligible prerequisite(s) for Commuting *	Please list your most recently attended retreats; include teacher names, dates, length of retreat (# of retreat nights), type of retreat. List only on-land/in-person retreats if that is the requirement of the prerequisite.< br/> IF YOU DO NOT MEET THE PREREQUISITE, PLEASE DO NOT CONTINUE. We will have to cancel your registration if you do not meet the prerequisite.
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
By joining this list, you’re also agreeing to join our email list.	I AGREE to join your email list.Uncheck the box if you do not wish to join our email list.

4 Demographics