Forest Refuge Application

Complete the information requested below, then click the "Submit Application" button at the bottom of the form. Once your application is submitted, you will receive a Confirmation Code — please quote this code in any future correspondence.

Retreatant Information

First Name
Last Name
Middle Initial
Email  
Address
City
Country
State/Prov
Zip/Postal Code
Day Phone
Evening Phone
Cell Phone

Application Information

 

General Information

 
Female
Male
Transgender or gender diverse
    (e.g. gender queer, gender fluid, agender, etc.)
 
 
 
 
 

Tell Us About Your Practice

 




Medical Questions


Yes No
 
 
 


Yes No

Yes No


Yes No

Yes No

Silence, Personal Retreat & Intention

Yes No
Yes No

Yes No

References

Yes No
Yes No

 
Yes No

Please submit your application. Provided you have answered all the questions, a Confirmation Code should immediately appear on your screen. If no code number appears, your application did not go through. Please check that you have completed the form correctly and disabled all script blockers, and submit it again. If you have any questions, contact the Forest Refuge by calling 978-355-2063 or emailing fr@dharma.org.



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