Mindful Living

Mindfulness Meditation Retreat Registration

Name:
Address:
Address 2:
City:
State/Province:
Zip/Postal Code:
Phone- Work:
Phone- Home:
Phone- Cell:
Email:
How did you find out about this retreat?

What brings you to the retreat? In other words, why are you considering it?

Please provide a brief description of your experience with mindfulness meditation. For example, are you a beginner, have you practiced another kind of meditation, have you had formal mindfulness training?

Please confirm the date/times for your Mindfulness Meditation Retreat:
	January, 1/15/10 - 1/17/10 September, 9/17/10 - 9/19/10
Please help us complete our records by providing us with your emergency contact information.
Emergency contact's name:
Relation to you:
Phone- Work:
Phone- Home:
Phone- Cell:

You may reserve a place by making a $100 NON-REFUNDABLE deposit, by clicking here.

Upon completion and submission of this registration form, you will receive confirmation of your place at the Mindfulness Meditation Retreat. If you do not receive notification, please call 713 522 7032 or email us.