Register for Santikaro’s Retreat Lake Tahoe Retreat with Santikaro "*" indicates required fields Step 1 of 4 25% FacebookThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formRetreat: Start Date*This field is for admin purposes and hidden from the frontend. Please fill in the Start Date by scrolling down to Advanced > Default Value MM slash DD slash YYYY This field is hidden when viewing the formRetreat: End Date*This field is for admin purposes and hidden from the frontend. Please fill in the End Date by scrolling down to Advanced > Default Value MM slash DD slash YYYY Name* First Last Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 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 No Emergency Contact*Emergency Contact Phone Number*Relationship to Emergency Contact?*LodgingPLEASE NOTE: All 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. For Room Assignments – Do you identify as?* Male Female Other Do you snore?* Yes No List any other conditions that might disturb a roommate (i.e. frequent bathroom trips, c-pap machine, etc.) Add RemoveAre you a light sleeper?* Yes No Roommate preference, if any.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) No 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 AccommodationsDo 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 No 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 RestrictionsVegetarian meals including eggs and dairy will be provided unless you indicate dietary restrictions below.Do you have dietary restrictions?* Yes No Please check all that apply:* 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.CarpoolingWould you be willing to offer a ride to someone from your area?* Yes No If yes, for how many?*Can they contact you directly?* Yes No Do you need a ride to the retreat?* Yes No If yes, from where?*DanaRegistration 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 DonationDonations 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 RequestIf 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 ExperienceYour answers to the following questions will be send to the retreat teacher.1. Please list your prior retreat experience including year, number of days, teacher, location and in what tradition?*If too many, summarize approximately how many retreats have you attended, over how many years, what’s the longest retreat and in what traditions? Note any previous retreats with this teacher.2. Please describe any psychological conditions that might make meditation practice difficult at this time (such as grief, recent loss, depression, addiction, psychological illness, etc.)If you are experiencing intense emotional states, please check with your therapist to determine if this is an appropriate time for you to undertake a silent meditation retreat. We recommend that residential retreats be undertaken only by participants who are experiencing a considerable degree of mental stability.3. Contact with the outside world is minimal. Retreatants need to be at ease with both silence and solitude. Noble Silence is required. Would this environment be problematic for you?* Yes No If yes, please explain below.*4. Is there anything else you would like the teacher to know that might help guide your practice during this retreat?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 understand that attendance is at the discretion of the teacher, and I agree to depart if requested by the teacher. I Confirm Liability WaiverCamp 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 PaymentHow will you make payment?*Select a payment option below. Online Payment Send a Check to the registrar Select a payment amount below:*A minimum deposit is required at this time or you may choose to pay in-full. If paying a deposit now, please pay your balance before the deadline, using the payment button online or send a check to the specified address on the retreat web page.$225 Deposit (04/09-12/26)$450 In-Full (04/09-12/26Total Payment MethodPayPal CheckoutCredit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Payment with a checkAfter clicking the submit button at the bottom of this page, please make the check Payable to Dharma Zephyr, note the retreat you are paying for and send to: DZIMC Retreat Registrar 603 S. Richmond Ave. Carson City, NV 89703 Δ
