Personal Retreat Application

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Date of Birth*

Gender*

Male
Female

When would you like to come – please include duration of the retreat you would like to do: two weeks, 20 days etc.?*

Please tell us why you would like to do a personal retreat at Orgyan Osal Cho Dzong.*

Which practice center(s) are you affiliated with?

As there will be little contact with others during your retreat, it would be helpful to know more about your practice background. How long have you been practicing?*

What kind of practice do you do?*

What retreats have you done?*

Have you done a solitary retreat before? If so when and where?*

Have you taken refuge? If so, with whom?*

Do you have any current health issues that would prevent you from keeping a solitary retreat during your stay? Please also list any medications you might be currently using, allergies that you might have, dietary restrictions, etc.*

Do you have, or have you ever suffered from anxiety, panic attacks, bi-polar disorder, mental illness, etc.? If yes, please give details*

In the case of an emergency, who could we contact? (Please give name, phone, address, email)*

Terms and Conditions*

I voluntarily agree that I am responsible for my own personal, physical, and emotional well-being during this retreat. I shall not hold The Palyul Foundation of Canada, Orgyan Osal Cho Dzong, the Teachers of Orgyan Osal Cho Dzong, the Palyul Foundation of Canada Board of Directors, the property owners, or any of their agents, representatives, or volunteers responsible for any damage to me or my property.