Being Alone Together: A Teacher-Supported Personal Retreat, July 24

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1 Welcome

2 Choose the dates of your stay

3 Lodging & Pricing

4 People in your group

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

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5 Participant Info

Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Phone *
Emergency Contact Name and Phone Number *	Please do not use your own name as an emergency contact
Gender *	This info is needed for accommodation purposes. Thanks.
Requested Roommate
To your knowledge, do you snore?	Yes No
Diet *	Gluten Free, Lactose Free, Enter Other Diet Notes in the box below
Do you have any food sensitivites or allergies? *	yes no
Please list any food allergies or sensitivities or any notes about diet we should know
Are you on any medications, have any drug allergies or medical/mental issues that we need to know in the event of an emergency? *	Yes No
List medical and/or mental issues (held in confidence)
Please list prescriptions and/or drug allergies (held in confidence)
Do you have any physical difficulties we should know about? *	Yes No
Please list these, including injuries from the past and present conditions. It will help the teacher and meditation instructors support your physical needs.
Comments	Please let us know any special circumstances or needs that have not been covered elsewhere
Can you offer a ride or need a ride? *	I need a ride OR can offer a ride No If registering for a group, choose the best option for the group
Arrival Air Flight #, Airline, Date and Time of Arrival	If you need a ride, please fill this out. If you don't know the details now, you can adjust your answers once you do.
If you Need a Ride from another place than the airport, please fill in your pickup location, day, and preferred time.
For those able to Give a Ride, please enter your travel date, where you are travelling from, and a preferred time for pickup
CANCELLATION POLICY *	I have read and accept the Cancellation Policy CLICK THE LINK TO VIEW POLICY
LIABILITY WAIVER *	I have read, understand and accept the Liability WaiverI hereby agree to hold harmless Dorje Denma Ling and Shambhala International, its officers, employees and volunteer staff, from and against any and all claims, liability, loss, cost or obligation, which may arise from participating in programs, employment and activities at Dorje Denma Ling.
CODE OF CONDUCT *	I have read, understand, and accept the Shambhala Code of ConductCLICK THE LINK TO ACCESS FULL CODE DETAILS: If I do not comply with these policies, I understand that I will be asked to leave the land, and that, depending on the offense, I could also be referred to either the independent review board for the Shambhala Code of Conduct or, the police, in the case of a legal offense.
NEWSLETTER SIGN-UP *	Please email me the Dorje Denma LIng newsletter.
Can we share your email with other participants and the teacher? *	Yes, I give permission to share my email.
May DDL share photos or videos that include you for promotional purposes? (You may withdraw your consent at any time by contacting us.) *	I am happy for photos or videos that include me to be used to share and promote future retreats (e.g., website, social media, print). I prefer not to have my image used for promotional purposes

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6 Retreat Info

What is your current main practice? *
What practice do you plan on doing during your retreat? *	Please be specific if you are doing Ngondro.
Do you intend to do the majority of practice in your room? *
In order to support you during your stay, please tell us if you have any mental health challenges we should know about. (Held in strictest confidence.) *	Retreat is a powerful practice that can trigger various mental states. It is essential that the teacher and meditation instructors understand your history so that they can support you during the retreat.
Preference: Chair or Cushion? *	We will have extras of each, please pick your primary setup. We have minimal support cushions that are saved for those flying in. If you are able, please bring anything extra you will need to enhance your comfort during the retreat.

7 Discounts, Scholarship & Volunteer (optional)

Are you 30 or under? *	Yes No By Selecting Yes, you confirm that you are 30 or under at the start of the program.
Input the code 30ANDUNDER at checkout and receive a 25% discount on program fee and meals.
Are you a monastic? *	Yes No
Input the code MONASTIC at checkout to receive an 80% discount on program fee and meals.
Will you be applying for a scholarship? *	Yes No Clicking yes does not qualify as applying. Follow the instructions below to complete the process.
Instructions to apply:	SCHOLARSHIP REQUEST LINK Fill out a Scholarship Request at least one month prior to the event. To complete your registration, choose "Check, E-Transfer, or Scholarships" for your payment option. We will contact you.
Are you wanting to volunteer before or after this retreat? *	Yes No
Instructions for volunteering for credit	Please complete your registration and choose "Check, E-Transfer, or Scholarships" for your payment option. Once complete, fill out a Volunteer Application. Credit must be earned prior to the retreat. We will contact you.

8 Donation Options

CAD $	Donation for Dorje Denma Ling Thank you for supporting your practice center!
CAD $	Donation to our Scholarship Fund Your generosity will help participants attend a retreat they may not be able to otherwise.
CAD $	Help Support Solar Sustainability at Dorje Denma Ling

9 Security Check

Security check

10 Payment

Discount Code

Option to pay credit card fees	I would like to help offset the fee for using my credit card. Dorje Denma Ling is charged when participants use credit cards. Help us become sustainable!
3% Option to pay credit card fees	$0

Sub Total	$0

Donations	$0

Taxes	$0

50% Deposit	$0

Pay	Choose to pay a deposit or the full amount right now.

Due Now	$0 $0

Remaining Balance	$0

Choose Payment Option

	SCHOLARSHIP APPLICANTS: CLICK REGISTER to complete the application/registration process. We will process your application and contact you with the new balance. TO PAY USING E-TRANSFER: 1) be sure to note the name of the program for which you are paying 2) send your e-transfer to finance@dorjedenmaling.org TO PAY BY CHECK: Finance Office Dorje Denma Ling 2280 Balmoral Rd, The Falls, Nova Scotia, B0K1V0, Canada Your registration or donation will be complete once we receive your payment. Click on the button below and these instructions will be repeated on the next page.

	You will be asked for payment details in the next step. Click the button below to continue.

	By submitting payment, you authorise Dorje Denma Ling to send instructions to the financial institution that issued your card to take payments from your card account in accordance with the terms of Dorje Denma Ling's agreement with you.