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SALT SPRING VIPASSANA COMMUNITY
(www.ssivipassana.org)
RESIDENTIAL RETREAT
DATES:______________________________
TEACHER(S): _______________________________________________
How many Vipassana residential retreats have you attended? _____________
Address ______________________________________________
E-mail * (required field)____________________________________
Phone ______________________
____I am not currently on your email list and would like to be added.
EMERGENCY CONTACT:
Relationship to you _______________________________
SIGNIFICANT DIETARY RESTRICTIONS: (please circle)
No Dairy, No wheat, Vegan, Other (explain) _______________________
ROOM ASSIGNMENT:
• Do You Snore? Yes / No
• Do you need a room on the ground floor? Yes / No
• Preferred roommate’s name (couples do not share a room)__________________________
• Do you have any medical needs or mobility limitations? ____________________________
____________________________________________________________________________
Please give any other information that will assist the manager in room assignment.
____________________________________________________________________________
CARPOOLING:
Would you be willing to offer a ride to someone from your area? Yes / No
Would you be willing to pick someone up at the Long Harbour ferry terminal? Yes / No
Would you be willing to pick someone up at the Fulford ferry terminal? Yes / No
PAYMENT:
I enclose my cheque for the full amount made out to SSVC:
___In-house
___Commuting
___Camping Total $______________
Please send your cheque together with the registration form.
If you are registering for more than one retreat please make out separate cheques for each retreat. Please do not include dana for the teacher in your cheque. There will be an opportunity to contribute at the end of the retreat. Thankyou.
CANCELLATION AND CANCELLATION FEES:
If you cancel prior to 4 weeks before the start of the retreat, you will receive a full refund.
If you cancel within 4 weeks of the start of the retreat, there will be no refund, unless we are able to fill your place from a waiting list.
Signature: ______________________________ Date: ___________________
Mail the Following:
- Registration Form
- Letter of Release (below)
- cheque(s)(made out to SSVC)
to: The Registrar, Stowel Lake Farm, 190 Reynolds Road, Salt Spring Island, B.C. V8K 1Y2
You will receive confirmation, and further information by email.
SALT SPRING VIPASSANA COMMUNITY
Residential Retreat: LETTER of RELEASE
VOLUNTARY PARTICIPATION
1. I acknowledge that I have voluntarily applied to participate in the Salt Spring Vipassana Community residential retreat to be held at Stowel Lake Farm, 190 Reynolds Road, Salt Spring Island, BC.
ASSUMPTION OF RISK
In consideration of being accepted as a retreatant for this meditation retreat, I assume all risk of damage or injury that may occur to me while practicing meditating, walking and working, at the Salt Spring Vipassana Community meditation retreat, as well as risks associated with hiking in the rural setting in which the retreat is held.
RELEASE
In consideration of being accepted as a retreatant for this meditation retreat,
I hereby agree that I will not make a claim against the Salt Spring Vipassana Community, nor against Stowel Lake Farm, their affiliates, employees, agents or volunteers, for injury or damage resulting from acts, howsoever caused, by any employee, agent, or contractor of either Salt Spring Vipassana Community, as a result of my participation in this retreat.
KNOWING AND VOLUNTARY EXECUTION
I have carefully read this agreement and fully understand its contents.
I am aware that this is a release of liability and a contract between myself
and Salt Spring Vipassana Community and/or its affiliated organizations, and sign it of my own free will.
Date_________________________________
Signature__________________________Printed name ________________________
