Salt Spring Insight Meditation

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Registration Form

** Download and print this registration form **

 SALT SPRING VIPASSANA SOCIETY

RESIDENTIAL RETREAT

DATES:  __________________________________________________________________

TEACHER(S): _____________________________________________________________

PERSONAL INFO:
Name    ____________________________________________     M/F (circle)     Age ____

Address _________________________________________________________________

City _________________________________________ Postal Code _________________

E-mail *  (required field)_____________________________________________________

Phone ______________________

EMERGENCY CONTACT:

Name ___________________________________  Phone # _______________________
Relationship to you ________________________________________________________

 

SIGNIFICANT DIETARY RESTRICTIONS:

(please circle) No Dairy, No wheat, Vegan, Other (explain) __________________________

ROOM ASSIGNMENT:
• Do You Snore?                                                                  Yes / No
• Do you need a room on the ground floor?                        Yes / No

• Preferred roommate’s name (couples do not share a room) ________________________________________________________________________

• Do you have any medical needs or mobility limitations? ___________________________________________________________________________

Please give any other information that will assist the manager in room assignment. ________________________________________________________________________ ________________________________________________________________________

 

CARPOOLING:

Would you like someone to give you a ride from your area?                      Yes / No

Would you be willing to offer a ride to someone from your area?              Yes / No

If so, are you willing for us to put them in touch with you directly ?           Yes / No

TO REGISTER AND SUBMIT PAYMENT, Mail the Following:

  • Registration Form
  • cheque(s)made out to SSVS ** Please NOTE the correct spelling = SSV’S’ instead of previous SSV’C’ (since we have become a registered ‘S’ociety). Thank you.

To:
The Registrar,
Stowel Lake Farm,
190 Reynolds Road,
Salt Spring Island, B.C. V8K 1Y2

You will receive confirmation by email.  

Date _______________________________

Signature __________________________

Printed name _______________________