Personal Retreat at Gomde California

Requested Retreat Start Date *
Retreat End Date *
First Name *
Last Name *
Email *
Phone *
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Birth Date *
Emergency Contact Info *	Please include their name, relationship to you, phone number, and e-mail address.
Emergency Contact Info #2 *	Please include their name, relationship to you, phone number, and email address.
Do you give us permission to transport you to the nearest medical facilities in case of serious illness or injury? *	Yes No
If no, please provide the contact information for a health care provider to contact in the case of an emergency
Are you a member of DharmaSun, Tara’s Triple Excellence, Rangjung Yeshe Institute, or any other program associated with Chokyi Nyima Rinpoche or the Ka-Nying lineage? *	Yes No
If yes, please specify
Have you engaged in personal retreat before? Please provide details *
Please describe all current medical conditions *	If you have none, simply write "none".
Do you have a history of suicidal tendencies? *	No Yes
If yes, please explain in more detail
What is your planned daily schedule for this retreat? *
Please write a detailed paragraph on your intention and plans for your private retreat at Gomde California. *
Who is your current teacher? Are they aware that you are doing this retreat? *
Please include any additional comments here.
Email newsletter	Please send me the email newsletter
What lodging accommodation do you prefer for your retreat? *

Guest 1		First Name* Last Name* Email*
Guest 1		First Name* Last Name* Email*

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