Dharma Gates | Multi-day Retreat Registration

Dharma Gates Retreat Application
Which retreat would you like to register for?*
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
Email
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
How did you find out about this retreat? (check all that apply)*

Social Media;Email;Website;Podcast;Dharma Gates Advising Program;Meditation Community;Friend;Other (please specify);
Other (How did you find out about this retreat?)
Friend's First Name
Friend's Last Name
Use this space to explain more about how you found out about this retreat and Dharma Gates
What draws you to apply to this retreat?*
Please share a brief summary of your experiences with meditation and spiritual practice.*

0/650
What teachers / methods /meditation techniques do you work with?
Have you attended a meditation retreat before? If so, please list the date, length, teachers, and hosting organization of the 4 most recent.*

(Note: it's ok if this is your first retreat and this is not applicable)0/650
Are you working with any mental health concerns right now? Please share as openly and honestly as possible so we can know how to best support you.*
Have you been formally diagnosed with any mental health issues?*
What were you diagnosed with?
Have you ever been hospitalized for mental health reasons?*
For which reasons were you hospitalized?
Are you currently taking any psychiatric medications?*
Which medications are you taking?
Please share any mobility, accessibility requirements, or specific needs related to your meditation practice to ensure you can participate comfortably in all aspects of the retreat. This includes accommodations for navigating the retreat space, posture support during meditation, or any other assistance you might need.
Do you have any other concerns or challenges particular to your life or meditation practice that would be helpful for us to know about?*
Housing and bathrooms will be shared, with exceptions for those who have medical or mental health needs. Would you prefer to be housed with folks who identify as women? Folks who identify as men? Or in mixed gender housing?*

identify as men;identify as women;in mixed gender housing;
If applicable, are you comfortable camping for the duration of this retreat?
Some retreats offer camping opportunities while others do not; please check the retreat page on the website for more information on the retreat you are signing up for.
If you are comfortable camping, can you provide your own camping gear?
Do you have any extra camping gear that you could bring for others? If so, what?
If you have any specific sleeping needs or conditions, please share here. Your comfort is important to us, and this information will help us make necessary accommodations.
Do you snore? This information will be helpful when assigning rooms.

YesNo
Are you currently in college or university?*
What is the name of your college or university?
Are you currently involved with a sangha, meditation community, or monastery?
What is the name of your sangha/meditation community/monastery? (please use the full organization name)*
What is your gender? (check all that apply)*

Male;Female;Non-Binary;Transgender;Genderfluid;Genderqueer;Other (please specify);
Other (Gender)
What are your pronouns? (check all that apply)

She/Her;They/Them;He/Him;She/They;He/They;Other (please specify);
Other (Pronouns)
What is your race/ethnicity? (check all that apply)

Native American and/or Indigenous;Asian;Black or African American;Hispanic or Latin;Middle Eastern or North African;Native Hawaiian or Other Pacific Islander;White;Multiracial or Biracial;Other Race or Ethnicity (please specify);
Other (Race/Ethnicity)
Are you from a low-income background?
Will you commit to attending the entire duration of this retreat?*
Do you have any allergies? Do you have any food sensitivities? Please indicate whether your dietary restriction is an allergy or an intolerance/sensitivity so we can communicate with the kitchen so they know how careful to be.*
Are you currently living in the United States or Canada?*

YesNo
Country*
City*
Wherever you are currently residing.
State/Province*
Are you interested in serving as a volunteer assistant cook for this retreat? Please read below for more details. For each retreat, two or three participants serve as assistant cooks. This role entails an average of 2-4 hours per day in the kitchen, so you may miss some of the meditations and group activities. Whenever you are not in the kitchen, you will be on the schedule with the other participants. Most assistant cooks have both experience on silent retreat and experience cooking for large groups. If you are interested, please let us know what cooking experience you have in the question below. The help is greatly appreciated!*

YesNo
If you are interested, please let us know what cooking experience you have in the field below.
The number of times you have cooked for groups, how comfortable you are cooking with larger quantities, etc.
Can you bring your own meditation cushion to the retreat? It is helpful for us if you are able to bring your own cushion/zafu. Also, please bring a zabuton, blanket or yoga met to place below your meditation cushion if you are able to. If you can borrow either of these from a friend that helps a lot! If not, it's we will have some for everyone's use.

YesNo
Out of care for the planet and the many sensitive beings that live on it, Dharma Gates is committed to reducing the carbon emissions of our retreats. To this end we calculate the approximate impact on the environment from retreat due to the travel of participants. What state will you be traveling from to get to this retreat?
And how will you be traveling to the retreat?*

Car (carpool/rideshare)Car (solo)BusTrainPlane
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone number*
Please enter a valid phone number.
If you are presenting with COVID-19 symptoms or any other serious illness, please do not attend the retreat. Depending on COVID rates, we may ask participants to take a rapid test in the week leading up to the retreat.*

I confirm that I understand the Dharma Gates health policy.
I would like to receive the Dharma Gates newsletter including information about future retreats, the advising program, and dharma resources. *
Dharma Gates occasionally uses photographs and video footage of our retreat events in our promotional materials. This may include, but is not limited to, use in our newsletters, social media platforms, and materials for donors and potential participants. By selecting "Yes," you grant Dharma Gates the right to use your image and video from the retreat for such purposes. Your participation helps us inspire more young people to engage in Buddhist meditation practices. Thank you for considering this request.*
Liability Waiver and Release
Please review Dharma Gates Retreat Liability Waiver and Release ("Liability Waiver") before proceeding.

I,Legal Name* , acknowledge that I am voluntarily participating in meditation retreat activities offered by Dharma Gates [Inc.] ("Organization"). I understand and acknowledge the Dharma Gates Retreat Liability Waiver and Release.
Please affirm that you have read and agree to the Liability Waiver and Release.*

I confirm that I have read and agree to the Liability Waiver and Release.
Retreat Deposit (Multi-Day Retreat)

This retreat is offered on a donation-basis in the spirit of Dana.

A refundable deposit of $100 via credit card is required to reserve a space in the retreat. You will recieve your deposit back, unless a) you are accepted into the retreat and cancel after the cancellation deadline, which is three weeks before the start date of the retreat or b) you are accepted into the retreat and do not attend or c) if you decide to donate your deposit.

If the deposit amount is unafforable to you, please reach out to us at team@dharma-gates.org.
Please select if you would like to donate your deposit or have it refunded after the retreat*

Retreat Deposit

Multi-Day Retreat Deposit

$100.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

Dharma Gates Retreat Application