First Name *
Last Name *
Email Address *
Telephone Number *
Address (please include postal code) *
Age *
Gender *	Male    Female
Occupation *
NAME AND PHONE NUMBER TO CONTACT IN CASE OF EMERGENCY
Emergency Contact's Name *
Emergency Contact's Phone Number *
ANSWERS TO THE FOLLOWING QUESTIONS WILL HELP THE TEACHERS DURING THE RETREAT, AND WILL BE TREATED CONFIDENTIALLY. PLEASE GIVE DETAILS.
Have you previously practiced Meditation? If so, with what teacher(s), where, and for how long? Please be Specific. *
Have you previously practiced any other type of meditation? If so, please give details. *
Have you studied with Michael Stone? When & Where? *
If you already have an established practice, what is your practice? *
Do you have any physical health conditions or disabilities that may affect sitting, movement (yoga) or walking meditation? Please give any details. *
Are you presently, or have you ever been, in therapy or treatment for any emotional or psychological conditions, such as depression, sleep disorders, eating disorders, abuse, etc.? If so, please give some information, including any medication being taken. *
Are you coming on retreat with a relative or friend? If so, please give their name. *
Are there any intentions for this retreat that you'd like to share? *
How did you hear about this retreat? *