Wildwood Camping Retreat Registration - Inward Bound Mindfulness Education (UK)

The information provided on this form is confidential and is used solely for registration purposes for this retreat.

At the end of the application you will be asked for your initial and name. This is your signature to your application. If the applicant is under 18, the electronic signature MUST be completed by the parent or guardian.

Participant First Name*

Participant Surname*

Participant Email*

Participant Phone*

Outside UK?

Participant Street Address*

Participant City*

Participant County*

Participant Post Code*

Participant Country*

Participant Gender*

Pronouns

Participant Date of Birth*

Parent/guardian contact must be different than that of young person. If applicant is over 18, a parent contact or alternate emergency contact is still required.

Parent/guardian First Name*

Parent/guardian Surname*

Parent/guardian Email*

Parent/guardian Phone*

Parent/guardian address same as participant address?*

Yes

Outside UK?

Parent/guardian Street Address*

Parent/guardian City*

Parent/guardian County*

Parent/guardian Post Code*

Parent/guardian Country*

How did you hear about the retreat?*

What is their name?*

What is their name? What school do they work at?*

Which social media service?*

Please explain where you heard about this retreat:*

Please describe your meditation experience: (no prior experience required)*

What is your inspiration for joining this retreat?*

Please describe any present circumstances that might be placing you under additional stress or make meditation difficult for you (e.g. loss of loved one, leaving home, divorce, COVID, etc.)*

Are you currently taking any medication?*

Learning about the diversity of our applicants helps us create an environment that supports every teen on retreat. Please check all that apply to you:

Please describe how you self-identify:

Please describe any special medical needs or conditions (including allergies to medications) or a history of physical illness or limitations:

Would any of these conditions be aggravated by or interfere with sitting meditation, walking or time outdoors?

Yes

I don't know

N/A

Please indicate any food allergies. We will be offering a balanced vegan/vegetarian diet that includes eggs, nuts and milk products.

Please note our cooking facilities are not gluten, dairy, nut or allergen-free. Some cross-contamination may occur.

Have you been in therapy in the last two years?*

Yes

Please explain why (e.g. diagnosis, treatment, dates):*

Are you currently in recovery from addiction to drugs or alcohol?*

Yes

We require that you have at least 3 months of sobriety before the start of the retreat in order to attend.

For how many months/years?*

We have a zero tolerance policy for the use of illegal drugs and alcohol during the retreat by anyone, including staff and participants.

Many of our participants need support getting to and from the retreat or would like to carpool. Your generosity in offering a ride is greatly appreciated. We will share contact information for ride sharing, so interested parties can coordinate directly. Please specify whether you can offer a ride, whether you need a ride, or neither.*

Is there anything else you think we should know in order to support you on retreat?

Ride to:

Ride from:

Have you answered all the questions above honestly and not left out important information?*

Yes

Please acknowledge that you have completed this application form in its entirety.*

I acknowledge that I have completed this application form in its entirety.

Retreat Rates: we offer a sliding-scale fee for this retreat

Please pay the rate you can afford, the top range of the scale allows our facilitators to be paid for this camp and also supports the bursary fund for lower income seats. Solidarity rate- £230, covers retreat costs, staff pay and supports scholarship seats Regular: £170, covers your retreat, including staff pay. Supported: £80, covers some basic retreat costs, excluding staff pay. Please be in touch if you need further support, no one will be turned away for lack of funds. If you are able to, please pay consider paying the solidarity rate.

Please specify your payment:*

Solidarity Rate (£230)

Base Rate (£170)

Supported rate (£80)

Other (let's have a chat)

Would you like to be added to our mailing list to receive updates and news?*

Yes

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