Fall 2021 Sesshin

Name

First Name

Last Name

Preferred pronouns

Example: "she/her/hers"

Phone number

Country

(###)

###

####

Phone

Mobile-Voice

Mobile-Text Only

Video Phone

Best way to reach you

Example: "mobile phone" or "video phone"

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of emergency contact:

Relationship to emergency contact:

Emergency contact phone:

Mobile-Voice

Mobile-Text Only

Video Phone

Health information:

Is there any pertinent health information we should know while practicing in community together with you:

Housing:

We offer shared rooms with 2 or 3 people per room. Each room has it's own private bath. Your roommate preference:

Male-identifying roommates

Female-identifying roommates

No preference

Do you need any additional accomodations:

We will do our best to accommodate your specific access or disability need:

Sleep:

We will do our best to create harmonious sleeping arrangements, please note anything that may impact your sleep or the sleep of others:

Food:

Retreat registration includes dinner on Wednesday evening, three meals on Thursday, Friday and Saturday, and two meals on Sunday. Meals will be vegetarian with vegan options. DO YOU HAVE ANY ADDITIONAL DIETARY RESTRICTIONS OR FOOD ALLERGIES?

Yes

If "yes" please explain:

Do you have a regular meditation practice?

Yes

Is this your first residential retreat?

Yes

Accessibility:

This sesshin (retreat) will be in English and ASL; do you require additional accomodations?

Registration:

$450.00 Full Sesshin: (includes meals, shared room and all sesshin activities)

$200.00 Commuter Rate/Full Sesshin (Includes meals and all sesshin activities)

$250 Weekend Only: (Friday evening through Sunday Afternoon. Includes meals, shared room and all sesshin activities)

Scholarship Fund

Please consider donating to our scholarship fund, which will help make the retreat available to everyone:

$10.00

$25.00

$50.00

$100.00

Cancellation Policy: a $50.00 processing fee for all cancellations prior to March 1st. No refunds will be offered after March 1st. I understand and agree:

Yes, I understand and accept this policy

Payment Total

No Barriers Zen photo permission:

No Barriers Zen has my permission to use my photos and/or videos for promotional purposes. These images may be used for social media, website, and printed materials. I also understand that no royalty, fee, or other compensation shall be due to me for the use of these images:

Yes, I am willing to allow No Barriers Zen to use my picture

No, I do not want my picture used in any promotional material

Waiver Statement:

By choosing to attend the Fall 2021 Sesshin I agree and consent to the the following: •Voluntary Participation: I acknowledge that I have voluntarily requested to participate in No Barrier Zen's "Spring 2020 Sesshin", located at the St. Benedict Monastery of Bristow, VA. • Assumption of Risk: I am aware that participating in this event may involve strenuous activity such as yoga, physical work, and the risks associated with intensive meditation. These risks, although rare, may include unusual physical or psychological sensations associated with meditation and retreat activities. I am participating in these activities with the full knowledge of the potential risks involved, and I hereby agree to accept any and all risks of harm that may result from these activities.

I agree to all of the above waiver statements

Registration Form