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* 1. Please provide your information below.

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* 2. Emergency Contact Information

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* 4. Please tell us why you are interested in participating in this program?

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* 5. Please select the response best describing your physical health

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* 6. Medical/Psychological Information - please list conditions and medications that would help the organizers and teachers ensure your comfort. If none, please type "None".

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* 7. If you are under the care of a healthcare professional for physical or psychological needs, please provide a contact name and phone number we can use in case of emergency. If none, please type "None".

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* 8. Please list all medications you have been prescribed and will have with you at the retreat. If none, please type "No Medications".

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* 10. Information required by retreat centre for rooms and meals (enter NA if not applicable)

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* 11. There is a possibility that service dog(s) may be in attendance at this retreat with their owner(s). Please indicate if you have an allergy to dogs or if you have any other concerns related to this.

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* 12. Conditions for Attending Retreats and Intensives

Attending a retreat or a program offered as an intensive can be an opportunity to acquire the experience of mindfulness and self-compassion. Being away from the usual rush of our life is also important so that we can collect ourselves and practice without the pressures of that life. We hope this retreat or intensive will be your opportunity to develop a way of being in your life that is healthy.

Retreats and intensives can also be challenging experiences. In the silence and the various practices, emotions and deeply-held experiences have a chance to surface. With an increasing awareness of our body and mind states, we may connect with the needs of both body and mind. Sometimes this connection can be sweet and poignant. Sometimes these connections can be intense and emotional.

In order to make your time in retreat as beneficial as possible, we ask you to consider the points listed below before submitting your registration form:

What the retreat leaders can and cannot do for you:

· Leaders can encourage you to participate because you want to learn how to meet your life and to deepen your connection with yourself.

· You have provided the name of an emergency contact person in the form above. We will contact this person in case of physical or emotional emergency so that we can be assured of your safety and care. Be sure it is someone who can pick you up or assist you to get home or to your support network.

· Although we are health care professionals, we are not able to provide you with the specific care during the retreat that you may need or are entitled to simply because we do not know the details of your health history.

· To care for you appropriately, the leader(s) of the retreat may choose to call 911 if necessary.

· If it becomes evident that there are primary healthcare issues that need to be addressed and which may be obstacles to completing the retreat or intensive, the retreat leaders will discuss this with you. At their discretion, they may need to ask you to seek help for those issues immediately.

· If you are taking any prescribed or self-administered medication for physical or psychological health care, we ask that you do not discontinue the medications for the duration of the retreat.

What the retreat can and cannot do for you:

· Retreats and intensives are intended as skills training programs and not group therapy.

· Retreats and intensives are designed to teach participants the tools needed to develop and cultivate a mindfulness and self-compassion practice. They do not take the place of personal therapy.

· Some retreats are fully silent and there are no interpersonal communications, except with the retreat leaders when it is part of the program.

· Some retreats and intensives may include working with other members of the group. While participating in the group exercises or the direct interchanges with the retreat leaders is not compulsory, it is a key aspect of developing mindfulness and self-compassion.

· If you are not a resident of Ontario and not covered by the Ontario Health Insurance Plan (OHIP), please be sure you have the necessary health care insurance for your needs.  Be sure to bring your health care card and applicable insurance information/card(s) with you.

Your self-care commitment:

· I understand that personal safety and emotional well-being are the foundation of mindfulness and self-compassion training and that I am primarily responsible for my own safety.

· I will not push myself to do anything that feels distressing or harmful.

· If I feel overwhelmed, I will stop what I am doing or slow down until I feel comfortable again.

· If I need to discuss a personal matter, I am willing to consult with one of the retreat leaders.

Thank you for completing this registration form. The facilitators leading the retreat will review the information and someone will contact you if any further information is required.

Once your information is reviewed, a request for payment will be sent to you.

Please review the payment and cancellation policies below.

PAYMENT CONDITIONS

Deposit: $350.00
Remainder two weeks before retreat date - by October 4, 2019.
Total cost: $1350.00*

*Insurance may reimburse approximately $750 of the registration fee as psychological services.  Please check with your insurer.

CANCELLATION POLICY

If you have paid the deposit only:
Payments are refundable* less $175 if we are notified at least 4 weeks prior - by September 20, 2019.
The full deposit ($350) will be retained if cancelling more than 2 weeks prior - by October 4, 2019.

If you have paid the full amount:
Payments are refundable* less $175 if we are notified at least 4 weeks prior - by September 20, 2019.
The full deposit ($350) will be retained if cancelling more than 2 weeks prior - by October 4, 2019.
The full payment less $650 will be refunded* if cancelling within the last 2 weeks - on or after October 5, 2019.

*Less finance charges if paid by Paypal or credit card.

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