DZIMC Residential Retreat Registration – Santikaro August 13 @3:00pm – August 18 @1:00pm

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DZIMC COVID-19 and General Wellness Policy*

COVID-19 and General Wellness Policy
November 30, 2022
This policy has been developed to provide guidance on the COVID precautionary measures for in-person attendance at DZIMC sitting group meetings and retreats. Because our practice is based on lovingkindness (caring for ourselves and all beings) and ethical behavior, the goal of this policy is to provide a safe and comforting environment for our sitting groups and retreat attendees.
1. DZIMC will comply with the latest guidelines from the CDC and the State of Nevada. If there is a conflict between the CDC and Nevada requirements, DZIMC will follow the more restrictive requirements.
2. If you are sick (cold, cough, sore throat, runny nose, etc., or have had a fever, vomiting, or diarrhea in the past 24 hours) please do not attend a DZIMC in-person event.
3. All in-person attendees at DZIMC indoor meetings and retreats are strongly encouraged to be fully vaccinated and boosted. However, recent data shows that there is little difference in protection against viral transmission between unvaccinated adults and people who have been vaccinated. For this reason, we are not requiring attendees be vaccinated.
4. Masks are optional unless the CDC or Nevada guidelines change. We encourage mask wearing for people who are in an increased risk category.
5. DZIMC has developed a communication about compassion and caring for others as the basis for this policy. This will be sent out in the form of an email notice to the wider sangha and posted at events, whether they be sitting groups or retreats. Any changes in the policy will be communicated to the wider sangha.
6. Individual sitting groups may adopt a more restrictive policy (such as requiring masks and distancing) if they so choose.
7. For in-person residential retreats at Camp Galilee the following applies:
a. Attendees must sign-off that they are not sick (cold, cough, sore throat, runny nose, etc.) and have not had a fever, vomiting or diarrhea in the 24 hours prior to arrival.
b. Attendees must sign-off that they have not been exposed to COVID in the prior 5 days. If they have been exposed to COVID in the prior 10 days, but have tested negative after 5 days, they may attend provided they wear an N95 or KN95 mask for the duration of the retreat.
c. Attendees must take an Antigen (rapid) test within the 48 hours prior to arrival at Camp Galilee and provide a picture of the negative test result.
d. There will be rapid tests available at check-in if they are needed.
e. The exact requirements may be adjusted by the retreat committee and the retreat manager prior to the retreat.
f. If Camp Galilee and/or the Teacher have additional requirements, DZIMC will comply with those requirements.
Adopted by DZIMC Board Resolution on November 30, 2022

I have read and agree to the COVID-19 and General Wellness Policy

Please read and agree to the DZIMC COVID-19 and General Wellness Policy to continue.

Name*

First Last

Email*

Dates Attending: Start Date*

Month

Day

Year

End Date*

Month

Day

Year

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

The best phone number to reach you on.

Age*

Occupation*

How did you learn about this retreat?*

Is this your first residential retreat?*

Yes

Emergency Contact*

Emergency Contact Phone Number*

Relationship to Emergency Contact?*

Lodging

PLEASE NOTE: All participants should try to find a roommate ahead of time. Also participants must provide their own bedding (including sheets and blankets, or sleeping bags, pillows, towels, and toiletries). If you are flying and cannot bring bedding, please contact the DZIMC retreat registrar to request rental of Camp Galilee’s limited bedding.

Do you plan to camp?*

No, I would like a shared room (double occupancy)

No, I would like a single room (shared bath)

Yes, I would like a teepee (if available)

Yes, I will camp in my tent.

Yes, I will camp in my vehicle.

Roommate preference

Lodging at Camp Galilee is in dormitories and cabins. If requesting one or more particular roommates, please ensure that all parties request each other. Staff will try to accommodate such requests if possible based on availability.

Request a Single Room?*

Yes (Please read instructions below)

A limited number of single-occupancy rooms may be available for an additional charge, depending on attendance. To request a single room: Mail a separate paper check payable to Dharma Zephyr. Refer to the DZIMC website or contact the retreat registrar for the dollar amount for a single room and the address to mail the check to. This check will be held until shortly before the retreat and will be cashed only if we are able to offer you a single room; otherwise the check will be shredded. You will be notified either way.

Medical and Mobility Accommodations

Do you have any medical needs, mobility limitations physical limitations, or injuries that we should know about in selecting your room, or that may affect your ability to do sitting and walking meditation?*

Yes

If "yes," please describe, including any requested accommodations.*

Please give any other information that will assist us with your room assignment and your stay at Camp Galilee. Please Note: All dormitories/cabins and the meditation hall have a few steps, or paved or dirt/gravel ramps at the entrances. Ability to negotiate gentle hills is required, and some accommodations have short pitches of steeper dirt/gravel access.

Dietary Restrictions

Vegetarian meals including eggs and dairy will be provided unless you indicate dietary restrictions below.

Do you have dietary restrictions?*

Yes

Please check all that apply:

No Restrictions

Vegetarian (including eggs & dairy)

Vegan

Gluten Free

Lactose Free

Nut Allergies (specify below)

Additional dietary restrictions*

If there are certain ingredients that you cannot eat under any conditions for medical reasons, and any specific ingredients that you can eat instead, please list them. Type N/A if none.

Carpooling

Would you be willing to offer a ride to someone from your area?*

Yes

If yes, for how many?

Can they contact you directly?

Yes

Do you need a ride to the retreat?

Yes

If yes, from where?

Dana

Registration fees cover food, accommodation (Camp Galilee cook and staff), teacher’s travel and basic administration expenses. There will be an opportunity to offer donations/dana at the end of the retreat to support the teacher and the retreat manager.

Scholarship Donation

Donations to the scholarship fund may be made two ways: Electronically from the DZIMC Website (use the DONATE button and write “Scholarship Fund” on the note line). Do not combine with retreat registration fees. Or donate by mailing a separate check to the retreat registrar, payable to “Dharma Zephyr”. Write “Scholarship Fund” on the memo line. Refer to the Retreat Event Page on the DZIMC Website for Registrar contact information.

Scholarship Request

If you would like to request a scholarship please review our Scholarship Policy, and send the retreat registrar a brief written statement outlining the reason for the request.

Retreat Experience

In order to guide you in practices that will be beneficial, please answer the following questions about your medical, psychological and meditation history. The information is strictly for the confidential use of teachers and this sheet will be destroyed after the retreat.

1. Please list dates & locations of previous retreats with Santikaro (estimation):*

2. List teachers and dates of other insight meditation retreats (three most recent):

3. Indicate any other meditation experience or spiritual traditions you are currently involved with: or have had a significant influence*

4. What is your current daily or weekly spiritual practice:

5. Do you have any history of physical illness or limitations which may make sitting, standing or walking difficult for you?

Yes

Please specify:

6. Have you ever experienced or been diagnosed with depression, eating disorders, anxiety, drug/alcohol addiction, significant trauma or any other psychological condition?

Yes

Please specify condition(s) and date(s) if within last 5 years or you think it might impact this retreat:

7. Are you currently taking medication for any physical or psychological condition?

Yes

Please specify condition and medication, if we should know about it:

8. Have you ever attempted to take your life?

Yes

If so, please state when.

9. Describe any present circumstances which might be placing you under additional stress or make meditation difficult for you (i.e. recent loss of a loved one or job, substance abuse, fasting.)

10. Any additional comments you would like to convey to Santikaro?

If you are attending the retreat with your partner, family member, or close friend, please indicate their Name belo (for interview group allocation purposes)

All of the above information is correct to the best of my knowledge.*

By selecting “confirm” below and submitting this form, I confirm that all of the above information is correct to the best of my knowledge. I agree to take full responsibility for myself during this retreat and observe the guidelines and instructions throughout the duration of the retreat, including attending all scheduled interviews with the teachers. I understand this retreat is undertaken and continued with the agreement of both the teacher(s) and the center directors.

I Confirm and Agree.

Liability Waiver

Camp Galilee and DZIMC Liability Waiver*

ASSUMPTION OF RISK / RELEASE OF LIABILITY / INDEMNITY

I acknowledge that I have voluntarily applied to participate in this meditation retreat sponsored by Dharma Zephyr Insight Meditation Community.

I am aware that participating in this event may involve strenuous physical activities such as work meditation, yoga, or movement classes, as well as risks associated with hiking, contact with wildlife, and hazards associated with an outdoor environment including rocks, embankments, water, and waves. I am also aware that this is a silent meditation retreat and that participants in such retreats may experience intense and unusual psychological, spiritual, and /or physical states of mind and body arising from the meditation and associated retreat activities. I am voluntarily participating in these activities with full knowledge of the risks involved, and hereby agree to accept any and all risks of harm that may result from these activities.

As consideration for being permitted by Dharma Zephyr Insight Meditation Community and Galilee Episcopal Camp and Conference Center to participate in these activities and use the facilities provided, I hereby agree that I, my assignees, heirs, distributees, guardians, and legal representatives will not make a claim against, sue, or attach the property of Dharma Zephyr Insight Meditation Community, Galilee Episcopal Camp and Conference Center, or any of their affiliates, employees, agents or volunteers, or any of their affiliated organizations for injury or damage resulting from acts, howsoever caused, by any employee, agent, or contractor of these organizations, or any of their affiliated organizations, as a result of my participation in this event, except when an employee, agent, or contractor of Dharma Zephyr Insight Mediation Community, Galilee Episcopal Camp and Conference Center, or any of their affiliated organizations exhibits gross negligence, or intentionally acts in a manner likely to lead to my being harmed. I hereby release Dharma Zephyr Insight Meditation Community, Galilee Episcopal Camp and Conference Center, and any of their affiliated organizations from all actions, claims or demands that I, my assignees, heirs, distributees, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my participation in this event, except when an employee, agent, or contractor of Dharma Zephyr Insight Meditation Community, Galilee Episcopal Camp and Conference Center, or any of their affiliated organizations exhibits gross negligence or intentionally acts in a manner likely to lead to my being harmed.

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 Dharma Zephyr Insight Meditation Community, and/or their affiliated organizations, and sign it of my own free will.

I acknowledge that I have voluntarily applied to participate in a meditation retreat sponsored by Dharma Zephyr Insight Meditation Community

Payment

How will you make payment?*

We encourage online payment for this retreat, however, if sending a check, please make it out to DZIMC and note “Santikaro’s Retreat”. Send it to: DZIMC – Retreat Registrar PO Box 4401 Carson City, NV 89702

Online Payment

Send a Check to the registrar

Select a payment option below:*

A minimum deposit of $350 is required at this time or you may choose to pay in-full. If paying a deposit now, please pay your remaining balance by 08/03/2023.

Total

Name

This field is for validation purposes and should be left unchanged.

DZIMC Residential Retreat Registration – Santikaro August 13 @3:00pm – August 18 @1:00pm

"*" indicates required fields

Step 1 of 5

20%

DZIMC COVID-19 and General Wellness Policy*

I have read and agree to the COVID-19 and General Wellness Policy

Please read and agree to the DZIMC COVID-19 and General Wellness Policy to continue.

Name*

First Last

Email*

Dates Attending: Start Date*

Month

Day

Year

End Date*

Month

Day

Year

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

The best phone number to reach you on.

Age*

Occupation*

How did you learn about this retreat?*

Is this your first residential retreat?*

Yes

Emergency Contact*

Emergency Contact Phone Number*

Relationship to Emergency Contact?*

Lodging

Do you plan to camp?*

No, I would like a shared room (double occupancy)

No, I would like a single room (shared bath)

Yes, I would like a teepee (if available)

Yes, I will camp in my tent.

Yes, I will camp in my vehicle.

Roommate preference

Request a Single Room?*

Yes (Please read instructions below)

Medical and Mobility Accommodations

Yes

If "yes," please describe, including any requested accommodations.*

Dietary Restrictions

Vegetarian meals including eggs and dairy will be provided unless you indicate dietary restrictions below.

Do you have dietary restrictions?*

Yes

Please check all that apply:

No Restrictions

Vegetarian (including eggs & dairy)

Vegan

Gluten Free

Lactose Free

Nut Allergies (specify below)

Additional dietary restrictions*

If there are certain ingredients that you cannot eat under any conditions for medical reasons, and any specific ingredients that you can eat instead, please list them. Type N/A if none.

Carpooling

Would you be willing to offer a ride to someone from your area?*

Yes

If yes, for how many?

Can they contact you directly?

Yes

Do you need a ride to the retreat?

Yes

If yes, from where?

Dana

Scholarship Donation

Scholarship Request

If you would like to request a scholarship please review our Scholarship Policy, and send the retreat registrar a brief written statement outlining the reason for the request.

Retreat Experience

1. Please list dates & locations of previous retreats with Santikaro (estimation):*

2. List teachers and dates of other insight meditation retreats (three most recent):

3. Indicate any other meditation experience or spiritual traditions you are currently involved with: or have had a significant influence*

4. What is your current daily or weekly spiritual practice:

5. Do you have any history of physical illness or limitations which may make sitting, standing or walking difficult for you?

Yes

Please specify:

6. Have you ever experienced or been diagnosed with depression, eating disorders, anxiety, drug/alcohol addiction, significant trauma or any other psychological condition?

Yes

Please specify condition(s) and date(s) if within last 5 years or you think it might impact this retreat:

7. Are you currently taking medication for any physical or psychological condition?

Yes

Please specify condition and medication, if we should know about it:

8. Have you ever attempted to take your life?

Yes

If so, please state when.

9. Describe any present circumstances which might be placing you under additional stress or make meditation difficult for you (i.e. recent loss of a loved one or job, substance abuse, fasting.)

10. Any additional comments you would like to convey to Santikaro?

If you are attending the retreat with your partner, family member, or close friend, please indicate their Name belo (for interview group allocation purposes)

All of the above information is correct to the best of my knowledge.*

I Confirm and Agree.

Liability Waiver

Camp Galilee and DZIMC Liability Waiver*

I acknowledge that I have voluntarily applied to participate in a meditation retreat sponsored by Dharma Zephyr Insight Meditation Community

Payment

How will you make payment?*

Online Payment

Send a Check to the registrar

Select a payment option below:*

A minimum deposit of $350 is required at this time or you may choose to pay in-full. If paying a deposit now, please pay your remaining balance by 08/03/2023.

Total

Name

This field is for validation purposes and should be left unchanged.

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DZIMC Residential Retreat Registration – Santikaro August 13 @3:00pm – August 18 @1:00pm

Please read and agree to the DZIMC COVID-19 and General Wellness Policy to continue.

Lodging

Medical and Mobility Accommodations

Dietary Restrictions

Carpooling

Dana

Scholarship Donation

Scholarship Request

Retreat Experience

Liability Waiver

Payment

DZIMC Residential Retreat Registration – Santikaro August 13 @3:00pm – August 18 @1:00pm

Please read and agree to the DZIMC COVID-19 and General Wellness Policy to continue.

Lodging

Medical and Mobility Accommodations

Dietary Restrictions

Carpooling

Dana

Scholarship Donation

Scholarship Request

Retreat Experience

Liability Waiver

Payment

Donate to Dharma Zephyr