Harvard Spring Break Retreat

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This retreat is ONLY for students enrolled at Harvard University.

First Name

Last Name

Email

Phone

Outside U.S.?

Street Address

City

State

Province/State

Zip/Postal Code

Country

Gender

Date of Birth (MM/DD/YYYY)

Emergency contact during the retreat:

Emergency contact name:

Emergency contact phone:

Please specify whether you are an undergraduate or graduate student

Undergraduate studentGraduate student

Please specify the name of your school

Please indicate any special dietary requirements you want us to know about:

iBme Celebrates Diversity: Learning about the diversity of our applicants helps us create an environment that supports every teen on retreat. Please check all that apply to you:

Please describe here if applicable:

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All fields are required. If a field does not apply please write N/A.

Please list dates of any previous meditation retreats you have attended - please include teacher names and tradition:

If you have a current daily/weekly spiritual/meditation practice please describe below:

Have you ever had or been treated for a psychological condition such as depression, eating disorder, drug/alcohol addiction, anxiety disorder, psychosis, schizophrenia, mania or any other psychological condition?

YesNo

Please specify condition(s) and date(s):

Are you currently taking medication for any psychological conditions?

YesNo

Please specify the condition and list the medications and dosage:

Are there currently conditions in your life which may be placing you under stress, or which might make meditation difficult for you at this time (e.g. recent loss of a loved one, substance abuse/withdrawal, relationship ending)?

Are there any additional comments or information you would like to convey to the teacher(s)?

Please acknowledge that you have completed this application form in its entirety.

I acknowledge that I have completed this application form in its entirety.

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The non-refundable fee for this retreat is $100.

Please select your method of payment:

By credit cardBy checkThis fee is a financial hardship and I request assistance.

Payment Acknowledgment

I understand that this tuition payment is not refundable.

Credit card details

All online payments are securely processed through our Authorize.net payment gateway.

Billing First Name

Billing Last Name

Billing Email

Credit Card Number

Expiration Month

Expiration Year

Card Verification Value (CVV / CSC)

Check instructions

Please make check payable to iBme, Inc. and send to: iBme, PO Box 516, Concord, MA 01742

Harvard U ID#

Authorization

I authorize Harvard College to share limited information about my level of financial need with the Center for Wellness, in order to determine my eligibility for a waiver of the program participation fee.

Current Payment

Retreat Payment: $

Hidden fields

Authorize

indigenous	person of color
LGBTQIA+	transgender, gender non-conforming
visually impaired	hearing impaired
physically impaired	I self identify in other ways