December Retreat Application

    FIRST TIME APPLICANT INFORMATION


    PRACTICE HISTORY

    The purpose of collecting this information is for the retreat teacher to help guide your practice. Please include as much information as possible below:












    MEDICAL CONDITIONS

    You must complete this portion of the retreat application even if you have informed us of medical issues before please include the information again. We request the following information to help us determine whether or not participation in a retreat will aggravate a serious medical condition, endanger a participant's health, or disrupt the functioning of a retreat. The information provided will be kept strictly confidential to protect the applicant's privacy.

    Please include:
    -Serious back or leg ailments
    -Dizziness, palpitation, or shortness of breath due to meditation
    -High or low blood pressure
    -Heart Problems
    -Major surgery or infections disease
    -If you have been treated for serious emotional or psychological symptoms

    Please briefly state the nature of each problem and the current condition. If you have no medical conditions please type None. (required)

    By clicking "Send Application", I testify that all the information I have provided Tallahassee Chan Center is correct and complete. I understand that if I withhold any necessary information, I may be excluded from future participation. If I am accepted, I agree to finish the entire event. I understand that if I leave the event without permission, my application to future events may not be accepted. You will need to sign a liability waiver prior to attending the retreat.