Name *

First Name

Last Name

Phone *

Best phone number to reach you

Country

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Can you receive text messages at this number?

Yes

No

Do you have any different physical abilities? *

Yes

No

Will you be driving to this retreat? *

Yes

No

Unsure

Are you here with someone you know? *

Yes

No

Is English your primary language? *

Yes

No

Emergency Contact: Phone *

Country

(###)

###

####

In case of medical emergency, if necessary, may we consult with your doctor? *

Yes

No

I don't have a doctor

Phone

Country

(###)

###

####

Are you currently seeing a therapist or psychiatrist? *

Yes

No

May we contact your therapist in emergency? *

Yes

No

Phone

Country

(###)

###

####

I give permission for my therapist to share information with Deep Mindfulness Collective *

Yes

No

N/A

READ CAREFULLY – Please check all that applies *

This is my first residential retreat ever

This is my first residential retreat with the Deep Mindfulness Collective

I am a snorer

I use a CPAP machine

I am requesting a handicap accessible room

Preferred gender for shared rooms is: *

Because this is a very small retreat taking place in a house, if you choose a shared room, we cannot guarantee you will be paired with your preferred gendered roommate. But we will take your preference into account.

All Gender

Female Roommate

Male Roommate

I am relatively familiar with the following: *

Shinzen Young's Meditation Techniques and System

Dzogchen

Zen Meditation

Heart Practice (metta, Brahmaviharas etc.)

Tibetan

Mental Health and Meditation - 1 *

When meditating for extended periods of time, difficult psychological experiences can arise. Please read the items below and check all boxes to indicate that you understand and agree. • In order to move forward in a responsible way, we need you to consider and honestly assess if you can answer yes, to each of the following questions: If I have a history of mental health challenges I will check in with a mental health professional (or a support network that I deem sufficient to support me) before embarking on this retreat.

Yes, I agree

No, I do not

Mental Health and Meditation - 2 *

I understand that mental health challenges may potentially arise for some when meditating for extended periods of time. I do not hold Deep Mindfulness Collective, Janusz Welin or any of their agents responsible or liable for any difficulties I experience. If an issue does arise that cannot be resolved, I commit to resolving this through private arbitration.

Yes, I agree

No, I do not

Mental Health and Meditation - 3 *

I will take responsibility for monitoring my experience and will stop meditating and reach out for support from someone with the requisite expertise to address my challenges if that becomes necessary at any point during the retreat.

Yes, I agree

No, I do not

6. Do you have any condition or history of physical illness or limitations that may interfere with or might be aggravated by sitting or walking practice? *

If yes, please describe

Yes

No

7. Have you ever had or been treated for a psychological condition such as depression, eating disorder, drug/alcohol addiction, anxiety disorder, psychosis, schizophrenia, mania or any other psychological condition? *

If yes, please specify condition(s) and date(s)

Yes

No

8. Are you currently taking prescription medication for any physical or psychological conditions? *

If yes, please specify the condition(s) and list the medications and dosage

Yes

No

9. If you are taking medications for physical conditions, do they affect your psychological functioning? *

If yes, please describe the effects.

Yes

No

10. Have you experienced significant emotional, psychological or spiritual difficulty that affected your ability to function? *

If yes, please briefly describe it and when it occurred. Is it still occurring now?

Yes

No

11. Have you ever seriously contemplated or attempted to take your life? *

If yes, please state when.

Yes

No

12. Have you ever experienced trauma that has been emotionally difficult such as accidents, PTSD, childhood abuse, etc.? *

Yes

No

15. Are you currently working with any psychedelic medicines for therapeutic or in ceremonial settings? *

Yes

No

16. Have you considered working with psychedelic medicines for therapeutic or self exploratory purposes? *

I have considered it or have already explored this.

It's not something I've considered/ not interested.

PARTICIPANT'S AGREEMENT *

By applying to this retreat, you agree to: 1. Maintain the SILENCE required by the retreat container (including not using electronic devices unless in case of an emergency). 2. To attend the entire retreat - NO LATE ARRIVALS OR EARLY DEPARTURES. 3. To follow instructions given by teachers and staff to the best of your ability. 4. To attend instruction periods, seated meditation sessions, group activities, movement meditations, Dharma talks and interview sessions with the teachers. 5. To arrive on the day the retreat opens, between 2:00 - 4:00 P.M. on opening day and leave no sooner than 3:30 P.M. on closing day. 6. I agree to get a PCR test prior to the retreat, to receive a rapid test upon arrival and midway through the retreat. I also agree to follow Covid 19 safety protocols outlined by retreat staff.

Yes, I agree

No

Deposit *

AFTER I HIT SUBMIT, I agree to pay the full retreat cost or the deposit for the retreat. After you register we will reach out to complete the interview process. Or, I agree that I have already paid the deposit at a previous stage. (If you mark that you have or will pay the deposit and we do not receive a deposit, you may lose your spot in the retreat.)

Full Retreat Fee: $4900

Base Cost Deposit: $2450

I already paid at a prior stage.