Rooted in Renewal: Earth Wisdom Gathering Retreat (802R26)

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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? *
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.
Current Organization/Company *
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.
Self Evaluation	At the conclusion of the retreat you will be given a self-evaluation form to see what you came into retreat with and what you are leaving with.
Have you been on a mindfulness retreat? *	Yes No
If yes, briefly describe your experience. *
What feels supportive or nourishing about entering this time of retreat? *	Describe briefly.
In this shared space of practice, what conditions would help you feel safe, resourced, or held? *	Describe briefly.
What is calling for your attention or presence as you enter this period of quiet and mindfulness practice? As you slow down and listen inwardly, what is your body or spirit asking for in this time of quiet? *	Describe briefly.
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.

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4 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.

5 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. 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, this includes first floor rooming. 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.
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.
Snore *	No, I don't snore Yes, I snore
CPAP machine	No, I do not use a CPAP machine. Yes, I use a CPAP machine.
Allergies *	No food allergies Yes food allergies 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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6 Tell Us More

Who referred you, or how did you hear about this retreat? *
New to Spirit Rock? *	Yes-new to Spirit Rock No-not new to Spirit Rock
How did you hear about Spirit Rock? *
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
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.

1 Welcome

2 Additional Programs

Participants

3 Practitioner Details

4 Demographics

5 Accommodations and Food

6 Tell Us More