Massachusetts Fall Adult Retreat

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PARTICIPANT INFO

iBme will keep confidential all information provided in this application except as required for participation in the Retreat or as otherwise required by law.

Questions? registrar@ibme.info | (978) 254-7082

First Name

Last Name

Phone

Street Address

City

State

Zip Code

Date of Birth (MM/DD/YYYY)

Gender

What are your preferred pronouns?

Please note that by submitting this application you agree to be added to our mailing list. You may unsubscribe from our list at any time.

EMERGENCY CONTACT & DIETARY INFO

Emergency contact name:

Emergency contact phone:

Do you have any dietary requirements?

MEDITATION HISTORY

Have you ever been on a meditation retreat before?

YesNo

Please list the retreats you have attended, including dates, teacher names, and traditions:

Do you have a regular meditation practice, or a spiritual tradition you participate in?

YesNo

Please describe your current spiritual / meditation practice below:

MENTAL HEALTH BACKGROUND

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?

Yes

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

Are you currently taking medication for any psychological conditions?

Yes

Please specify the condition and list the medications and dosage.

Are there any stressful situations in your life which might make meditation difficult for you? (e.g., loss of a loved one, substance abuse/withdrawal, relationship ending)

YesNo

Please describe the stressful conditions below.

Additional Info

How did you hear about the retreat?

Is there anything else you would like to tell the retreat teachers?

Please check the box below.

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

PAYMENT INFO

Retreat Fee: $595

Deposit: $100

Please select your tuition

Retreat feeI would like to request financial aid

We have a limited number of partial scholarships that we will distribute on a first come/first served basis. Please pay the $35 application fee and provide a brief summary of your financial aid request below. We will follow up with you regarding your scholarship award.

Please select your payment method and pay the deposit amount or full retreat tuition.

Please select your payment method and pay the $35 application fee.

Payment select

Payment Method

By credit cardBy check

Please select current payment amount

Pay depositPay full tuition

Current payment amount

Credit Card

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

Billing First Name

Billing Last Name

Billing Email

Credit Card Number

Exp Month

Exp Year

CVV / CSC

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

Cancellation Policy

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Cancellation Policy:

If you cancel more than 3 weeks before the start of the retreat, your payment will be refunded minus a $100 administrative fee and the $35 application fee. We cannot offer refunds for cancellations made less than 3 weeks before a retreat because of our commitment to the retreat center. There is no refund if you decide to leave the retreat early. You may also refer to our cancellation policy on the retreat cancellation policy page of our website.

Please confirm that you have read and agree to our retreat cancellation policy above

I confirm that I have read and agree to the cancellation policy for this retreat.

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Total Current Payment: $

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