2014 – 100 Million Mani Retreat Registration Form

Step 1. Fill out the form and send

Personal Details

First Name* Last Name*

Birth Date* (Y/M/D) Gender*  Male Female

Contact Details

Email Address* Telephone*

Address*

Country* Language*

Emergency Contact Details

Name* Telephone*(incl. country code)

Ordination Details

Ordained monk/nun Ordained Name

Date of Ordination (Y/M/D) Level of Ordination

Previous Dharma Experience:

Have you attended Buddhist teachings before?*

 YES NO

Are you a regular visitor or member at a Buddhist centre?*
 YES NO

If so, which one?

Have you completed a long retreat before?*

 YES NO

If yes, how long?

Health Details

Please indicate any illnesses, medical conditions, allergies or injuries we need to be aware of;

Do you take any medications which the retreat organizers need to know about in the event of a medical emergency?*

 YES NO

If yes, please give details

Do you have or have you ever had any mental illness requiring medication, hospitalization or psychiatric counseling?*

 YES NO

If yes, please give details

Seating Requirements:

Do you need a meditation cushion?*  YES NO

Do you need a chair?*  YES NO

Volunteer skills at the retreat:

Could you please indicate if you have any skills that may be useful to contribute
to the retreat

Attendance at Retreat:

If not attending for full retreat, please indicate start and finish date of attendance.

Star: Finish:

Declaration *

I accept that the retreat organizers will call an ambulance should it be deemed I need medical attention and I accept that I shall be liable for any expenses incurred.

I have truthfully provided all the information asked of me on this form and hereby undertake to absolve FPMT Mongolia or any individual office holder from any legal or financial responsibility I may incur while attending the retreat

I acknowledge that I have read and understood this form and declaration:

Signed:

Retreat Cost:Attendance at this year’s 100 Million Mani Retreat is BY DONATION
includes full attendance at retreat and vegetarian lunch each day; Sweet rice or bread together with tea, will be served each morning;

Retreat Supplies

Retreat book - English $19 (Note: If you have the 2009 edition, please bring with you) YES NO

Full amount to be paid in USD (inclusive of Retreat cost, retreat book) = USD

Step 2. Secure Payment

Go to Our Secure Online Offering Page (128bit)

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