The Buddha's Way to Happiness: Insight Meditation Retreat (4 days) - HC

February 5 – 9, 2014 (Wednesday to Sunday)

Complete the information requested below, then click the "Submit Registration" button at the bottom of the form. Once your registration is submitted, you will receive a Confirmation Code — please quote this in any future correspondence. Within a week, you should receive further information from us regarding your registration status.

Retreatant Information

First Name
Last Name
Middle Initial
Email
Address
City
Country
State/Prov
Zip/Postal Code
Day Phone
Evening Phone
Cell Phone

Retreat Fees

IMS's fees are on a sliding scale basis, and do not include compensation for the teachings. There will be an opportunity to offer donations to the teachers and to IMS at the end of this retreat. Please consider selecting the highest rate you can reasonably afford to help ensure retreats are available to all. Note that any amount paid above the Base rate is a tax-deductible donation. Sliding scale rate you select:
	Sustaining $485 (This represents IMS's actual cost for this program.)
	Mid $405
	Base $320

Amount you will pay today:
	Sustaining $485
	Mid $405
	Base $320
	Deposit $180

Please read our registration information and cancellation policy.

Retreat Center Questions

Year of Birth (YYYY)
Do you smoke?
Yes No
Do you snore?
Yes No
Have you attended a retreat at IMS before?
Yes No
Have you attended a meditation retreat elsewhere before?
Yes No
All accommodations are single rooms with locking doors. Bathroom blocks are located on each floor, each toilet and shower stall is fully private and lockable.
To help us provide the most appropriate accommodation for you, please answer the following questions. Within our space constraints, we will do our best to honor your request.
How do you identify your gender?
Female
Male
Transgender or gender diverse (e.g. gender queer, gender fluid, agender, etc.)
Which would be your preferred accommodation?
Floor for all genders, or no preference
Floor for women
Floor for men
Please also indicate any mobility or other limitations, or needs we should be aware of in assigning your room and having you on retreat with us. (You are also welcome to contact us at rc@dharma.org or call us at 1-978-355-4378.)

Mailing Information

Are you on the IMS mailing list (postal or e-mail) already?
Yes No
Do you wish to receive our mailings?
Yes No
May we share your mailing address with your teachers?
Yes No
Do you wish to be on our e-mailing list?
Yes No
May we share your email address with your teachers?
Yes No
Where did you hear about the Retreat Center?

Financial Assistance Application

Occupation
Annual Income
Number of dependents (including yourself)
To help us fund your retreat, please indicate if your circumstances match any of the following: People of Color
Yes No
Teen Ages 15-19
Yes No
Ages 18-26
Yes No
None of the above
Yes No
Please describe why you are seeking financial assistance to attend this retreat:

Payment Information

Note: Address below must match what is on file with your credit card company or the transaction will be declined.

First Name
Last Name
Middle Initial
Email
Address
City
Country
State/Prov
Zip/Postal
Phone

Payment Method	Visa Mastercard
Credit Card #
CVV Code
Expiry Date

Additional Donation

I would like to contribute an additional amount to IMS.
$

I have read the registration information and cancellation policy. Click here to review.

Please submit your registration. Provided you have answered all the questions, a Confirmation Code should immediately appear on your screen. If no code number appears, your application did not go through. Please check that you have completed the form correctly and disabled all script blockers, and submit it again. If you have any questions, contact the Retreat Center by calling 978-355-4378 or emailing rc@dharma.org.

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