Wilderness Retreat Questionnaire

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Do you have any dietary restrictions? *

Gluten Free

Dairy Free

Pescetarian

Vegetarian

Vegan

None

What gear will you need? Check all that apply.

Tent

Sleeping Bag

Sleeping Pad

What is your comfort level outdoors?

I'm comfortable camping

Camping makes me nervous but I love the outdoors

Just being in nature is out of my comfort zone

What is your meditation practice like? *

I'm new to the whole meditation thing

I've attempted to meditate, off & on

I have a somewhat regularly practice

I have years of a dedicated practice

Part of this experience is going offline. How comfortable are you with being offline? *

Nervous About It

Can't Wait!

Not sure yet

During the retreat we will be taking photos. What level of permission do you give for use of photos in promotional material?

You may use any photo I am in.

You may use my photo as long as you cannot identify me. (Photos from far away or behind for example)

You may not use any photo with me in it.