Five Invitations Retreat

Personal Information

* First Name:
* Last Name:
* Email Address:
* Confirm Email Address:
* Address 1:
* City:
State:
ZIP Code:
Country:
* Cell Phone:
* List Emergency Contact Information. Include the person's Full Name, Relationship, Cell Phone Number, Email Address
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Type	Fee
Individual	$1,500.00
Couple	$2,400.00

*
Dietary Restrictions (check all that apply)
- None
- Vegetarian
- No Dairy
- Other Restrictions (specify below)
Describe other Dietary Restrictions.
* Do you have any significant health concerns that could impact your participation? Please describe (If you would rather discuss by phone please indicate below).
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* Do you have, or have you ever had, any mental health challenges such as depression, anxiety, addictions, suicidal ideation or other? If you would prefer to discuss by phone please indicate below and leave your phone number.
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There are a limited number of single rooms. Most participants will be accommodated in shared rooms (2-4 people). Priority for single rooms is given to those with special needs. Please select your reason for a single room request. Give brief description below. We cannot guarantee single rooms.
- I have health/age related issues
- I am a snorer
- I use a CPAP machine
- I have mobility issues
Briefly describe why you require a single room.
*
Do you have a regular mindfulness meditation practice or contemplative practice?
- Yes
- No
*
How often do you meditate or do contemplative practice?
- Daily 20 minutes or more
- 3-5 times per week
*
Do you have any training experience Frank?
- None
- Attended 1-2 day workshop
- Attended a 3-7 day residential retreat
- Attended a public talk or conference
* If registering as a couple, what is the name of your partner?

*
Your Role in Caregiving?
- Family Caregiver
- Physician
- Nurse Practitioner/Nurse RN or LVN
- Social Worker/Counselor/ Psychotherapist/Psychologist
- Chaplain/Spiritual Services
- Para-Professional/CNA/HHA
- Complementary Health Practitioner
- Educator/ Community Organizer
- Volunteer
- Other (Briefly describe below)
*
Please help us understand where you generally provide care?
- Hospital/ Health Clinic
- Hospice or Palliative Care Service
- Non-Profit or Community Health Organization
- Residential or Skilled Nursing Facility
- Private Practice
- Educational or Religious Organization
- Home
- Other
If you selected other above briefly describe your role in caregiving,
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*
I can attend the entire retreat Thursday, June 15th, 2023 @ 5pm through Sunday, June 18th, 2023 @ 12 noon.
- Yes
- No