Virginia Teen Retreat

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This application will take about 30 to 60 minutes.

All information that you provide is confidential within iBme, but:

1) If you are under 18 all information will be viewable by your parent / guardian.

2) Your parent / guardian will also need to provide a signature on some pages.

Questions? | (978) 254-7082


What is your name?

What is your birthday and gender?

What is your contact info?


What is your address?

Transportation: Carpool
Please note that this year the transportation options for this retreat have changed. For carpools, teens and parents will be using to create and join carpools.

iBme Celebrates Diversity



Parent  / Guardian

How did you hear about this retreat?


These questions MUST be answered by the teen.

Admissions Phone Call
After you submit this application, you will receive an email with instructions on how to schedule your admissions phone call with an iBme staff member. This call is a required part of the admissions process. Please note that your acceptance into the retreat is contingent upon our review of your application and your admissions call.



EXAMPLE: “Peanuts - life-threatening when eaten - Epi-pen."

EXAMPLE: “Bee allergy - moderate - Benadryl."
iBme can accommodate most common allergies and food needs, but not all.
Special Medical Needs

Mental Health

Substance History

We require that teens have at least 3 months of sobriety before the start of the retreat in order to attend.

We have a zero tolerance policy
for the use of alcohol, marijuana, and illegal drugs during the retreat.

Confirmation from Teen


Medical Insurance

Inhalers & Epi-pens

  • With the permission of the parent, teens with asthma or life-threatening allergies will be allowed to keep inhalers & Epi-pens with them at all times.
  • We request that teens bring an extra inhaler or Epi-pen to be kept with iBme staff. 

List all medications below, one medication per row:










Medication Requirements

Based on state laws, iBme requires all participants to hand in medication to the health coordinator at the start of the retreat. These medications will be given to the participants based on their prescription, for the participant to self-administer. We require written parental permission (see below) for all medication taken while on retreat.

All medication must be brought in a correctly labeled pharmacy or manufacturer’s medication container. Medications will not be accepted in containers such as plastic bags or daily pillboxes. Medications will be distributed exactly as the container instructs. Please send enough medication to cover the duration of the retreat.

All medications will be kept by an iBme staff member in a secure location and returned to the participant at the close of the retreat.

Medication Permission & Release

TEENS UNDER 18: this section MUST be completed by a parent or guardian.


Please read this waiver and sign at the bottom.

I acknowledge that I have voluntarily applied to participate in the Inward Bound Mindfulness Education, Inc (iBme, Inc) retreat for teenagers and/or young adults entitled Virginia Teen Retreat, referred to below as "this event", at the premises of Serenity Ridge Retreat Center hereafter referred to as “facility”, in the city of Shipman, VA. I acknowledge that all information on this application is accurate and complete - including all medical information.


I am aware that participating in this event may involve strenuous physical activities such as work meditation (washing dishes, cleaning bathrooms, etc.), yoga, or movement classes, as well as risks associated with hiking in a rural setting including contact with poison oak and wildlife. I am also aware that this is an intensive meditation retreat and that participants in such retreats may experience intense and unusual psychological, spiritual, and/or physical states of mind and body arising from the meditation and associated retreat activities. I am voluntarily participating in these activities with full knowledge of the risks involved, and hereby agree to accept any and all risks of harm that may result from these activities. 

Consent is hereby given for the applicant to attend an iBme retreat. I hereby give consent for Inward Bound Mindfulness Education, its staff, and its volunteers to provide medical care to me or my child. This may include assisting participants with self-administering over-the-counter medications, offering basic First Aid, or determining if professional care at a hospital is necessary. I understand that for the safety of participants, it is iBme's policy to hold on to any medications that participants bring with them, including over-the-counter medications, and help participants to self-administer these medications when/if necessary. Permission is given for any emergency anesthesia, operation, hospitalization or other treatment (whether for an emergency or not) which might become necessary. I agree to be responsible for any and all costs associated with such treatment. All information will be kept confidential except that information may be disclosed to any medical or other provider as needed for my (or my child’s) care. If iBme arranges for treatment for me (or my child) by a medical provider, I authorize that medical provider to release information about me (or my child), and my (or my child’s) condition and treatment to iBme. I understand that failure to disclose medical information could result in serious harm to me (or my child) and fellow participants. If I (or my child) arrive at the retreat with a preexisting medical, behavioral or psychological condition which is not indicated on my medical form, I understand that this may affect whether iBme allows me to attend the retreat.


As consideration for being permitted by iBme, Inc and the retreat facility to participate in these activities and use their facilities, I hereby agree that I, my parents, my guardians, my assignees, heirs, distributees, and legal representatives will not make a claim against, sue or attach the property of iBme Inc or facility, their affiliates, employees, agents or volunteers or any of their affiliated organizations for injury or damage resulting from acts, howsoever caused, by any employee, agent, or contractor of iBme Inc or facility, or any of their affiliated organizations, as a result of my participation in this event, except when an employee, agent, or contractor of iBme Inc and facility, or any of their affiliated organizations exhibits gross negligence or intentionally acts in a manner likely to lead to my being harmed. I hereby release iBme, Inc, facility and any of their affiliated organizations from all actions, claims or demands that I, my parents, my assigns, heirs, distributees, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my participation in this event, except when an employee, agent, or contractor of iBme Inc or facility or any of their affiliated organizations exhibits gross negligence or intentionally acts in a manner likely to lead to my being harmed.


I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract among myself, iBme, Inc, facility and/or their affiliated organizations, and sign it of my own free will.


I do hereby confirm the consent given you with respect to your photographing or recording me or my child in connection with the iBme, Inc Teen Retreat. I hereby grant to you the right to use all the videos, photographs, and audio recordings which you may make of me or my child, and the right to use my name and/or child’s name or likeness in or in connection with publicly displaying the retreat or any other use of such video, picture, or audio recording.


The tuition for this retreat is: $2000

Scholarships are available based on family income.

Required Deposit: A deposit of 30% of the total payment is required to hold a retreat space.

Required Application Fee: A minimum payment of $35 is required to process this application.

Specify your payment:
Tuition: $

Deposit: $

Apply for Scholarship Assistance

iBme is committed to accessibility. We have developed our tuition structure to accommodate a wide range of family income.

The iBme sliding scale guideline is for participants to pay 1% of annual family income.

Your Tuition: $

Please pay the deposit amount shown below.

We will review your extenuating circumstances. Please pay the deposit amount below.
Your Deposit: $

Payment info

Make check payable to iBme, Inc. and send to: iBme, PO Box 516, Concord, MA 01742
Would you like to include a scholarship gift to iBme with your payment?

Making a gift to iBme helps us maintain our generous scholarship aid: 
we have never turned a teen away for lack of funds.

iBme, Inc. is a tax-exempt 501(c)(3) charitable organization. Your contribution is tax-deductible to the extent allowed by law.


Instructions for Submitting Your Application

1) Press "SUBMIT" to proceed to the electronic signature page.

2) Review your application to make sure there are no mistakes.

3) Your electronic signature verifies your signature on all forms, and that your application is accurate to the best of your knowledge.

IF YOU ARE UNDER 18, the electronic signature process MUST be completed by your parent / guardian. They will be able to view your entire application.
Total Current Payment: $

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