Retreat Registration Form

PLEASE NOTE THAT THE RETREAT IS FULL. Please add yourself to the waitlist. Fill out the form as usual, but select "Waitlist" for your Housing Choice, and do not submit a payment. We will notify you via e-mail if a spot becomes available for you.

Use this form to register for the following retreat:

EMBRACING THE INNER CHILD WITH MINDFULNESS: The Art of Cultivating Compassion and Happiness

Friday June 14 - Wednesday June 19, 2019

A Mindfulness Retreat with Anh-Huong Nguyen and Thu Nguyen

Prindle Pond Conference Center, Charlton, MA

More information can be found on the retreat website.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Gender*

FemaleMaleNon-binary / third genderOther

Age

20 - 3536 - 5051 - 6566+

For 35(ish) and under, are you interested in being part of a Wake Up Dharma Sharing group?

YesNo

Any other family member attending? If so, please name below. (Please submit registrations for family members separately.)

PLEASE NOTE THAT THE RETREAT IS FULL. Please add yourself to the waitlist by selecting "Waitlist" for your Housing Choice.

Housing Choice*

WaitlistCamping - $300 [SOLD OUT]Shared Room Shared Bath - $400 [SOLD OUT]Double Wide bunk for couples, shared bath - $440 [SOLD OUT]Single with Private Bath (no window) - $440 [SOLD OUT]Single with Shared Bath - $440 [SOLD OUT]Hemlock Double (or Triple) with private bath - $450 [SOLD OUT]Single with Private Bath - $450 [SOLD OUT]

Sorry, but the housing choice you selected is sold out. Please choose a different option.

For shared rooms - list the name(s) of preferred roommate(s)

Separate multiple names with commas

Do you snore?

YesNo

Please list any special needs you have that we might accommodate in order to make this retreat a good experience for you (food allergies or sensitivities, mobility or physical challenges, etc.)

Is this your first retreat in the Plum Village tradition?

YesNo

Please describe your mindfulness experience

New to meditationNew to meditation in the Plum Village tradition of Thich Nhat HanhI practice in a meditation groupI practice in a meditation group in the Plum Village traditionI have received the 5 Mindfulness TrainingsAn Aspirant to the Order of InterbeingA member of the Order of Interbeing

If an Aspirant, list mentor name

Name of your Sangha (if applicable) and location

Number of years you have practiced meditation

Number of years in Plum Village tradition

If you are newer to this practice and retreats, would you enjoy having a sangha buddy to support you?

YesNo

Volunteer for Tasks

The retreat needs support in several areas. Please indicate if you have interest in helping with any of the following tasks. Training will be provided. Note that some tasks require you to arrive to the retreat early. As the retreat gets closer, someone will be in contact with you regarding this support.

Volunteer for Tasks

Donations

Donations are also appreciated. Our donations support the teachers or pay for scholarships. If you would like to donate, please enter the amounts in the boxes below, and it will be added to your total.

Donation for Scholarships

Donation for Teachers

Request for Financial Assistance

Please check this box if you are requesting need-based financial assistance (see full instructions on the retreat website).

Amount of Financial Assistance Requested (subject to confirmation)

Total owed

Total owed after FA

Based on your selections, you owe:

Accomodation	${housingChoice}
Donation for Scholarship	${donSchol}
Donation for Teachers	${donTeach}
Total	${totalOwed}

You owe a total of ${totalOwed}. Please write this number down as you will need it to complete payment later.

Based on your selections, you owe:

Accomodation	${housingChoice}
Donation for Scholarship	${donSchol}
Donation for Teachers	${donTeach}
Financial Assistance	-${finAssist}
Total	${totalOwedFA}

You owe a total of ${totalOwedFA}. Note that this amount assumes confirmation of the requested financial assistance. Please write this number down as you will need it to complete payment later.

Payment preference*

Credit CardCheck

To pay by credit card, please submit this registration form, then return to the retreat website to complete payment.

To pay by check, please submit this registration form, then mail a check to the address below. Please make the check payable to Mindfulness Practice Center, Inc., and include retreatant name on the memo line of your check.

MPC Treasurer
PO Box 848
Norwich, VT 05055

Photo Consent*

I grant permission to the Thich Nhat Hanh Foundation to use any photographs taken of me at this event for any legal use.I do not grant permission.

Additional Steps Are Needed to Complete Retreat Registration*

I understand that I need to pay in order to complete my registration.

There are errors with your registration form. Please scroll up and fix any errors before submitting.

Personal Information

Accomodations

Mindfulness Experience

Supporting the Retreat

Payment Preference

Submit Registration