retreat application: step 1 of 2

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retreat application: step 1 of 2

For Step 1 of your application, please fill out this registration information and pay the $35 application fee. Upon submission, you will receive an email with a unique link to complete Step 2 of your application. Please do this as soon as you're able - you are not signed up for retreat until you complete the full application. If we reach capacity and start a waitlist during this time, you will have the option to join the waitlist.

What is your name?

Participant Info

First Name

Last Name

Date of Birth

Did you attend a workshop or info session before applying?

YesNo

Are you under 18?

YesNo

What is your address?

Address

Outside U.S.?

Street Address

City

State

Province/State

Zip/Postal Code

Country

Please note that by submitting this application you agree to be added to our mailing list. You may unsubscribe from our list at any time.

Would you (the participant) like to be added to our mailing list and receive updates and news from Inward Bound Mindfulness?

YesNo

Parent / Guardian

Parent Info

Parent First Name

Parent Last Name

We require you to provide both teen and parent email address - we like to be able to communicate directly with parents AND teens.

Parent Email

Parent address same as teen address?

YesNo

Outside U.S.?

Parent Street Address

Parent City

Parent State

Parent Province/State

Parent Zip/Postal Code

Parent Country

Please note that by submitting this application you agree to be added to our mailing list. You may unsubscribe from our list at any time.

Would you (the parent) like to be added to our mailing list and receive updates and news from Inward Bound?

YesNo

Payment Info

Payment Info

Please select a payment method

credit cardcheck

Make check of $35 payable to Inward Bound Mindfulness Education and send to:
878 Washington St Unit #1119, Attleboro, MA 02703

The $35 application fee is nonrefundable. Please confirm that you agree to this policy by checking the box below.

I acknowledge that the $35 application fee is non-refundable.

To apply for a waiver of the $35 application fee due to financial difficulty, email registrar@inwardboundmind.org explaining your situation.

Billing First Name

Billing Last Name

Billing Email

Credit Card Number

Expiration Month

Expiration Year

CVV / CSC

Please consider covering the credit card processing fee for this transaction, which greatly helps to support Inward Bound's operation costs.

Yes, please add 3% to my transaction to cover the credit card processing fee.

Application Fee: $

Credit Card Processing Fee: $

Total Current Payment: $

all transactions are securely processed through Authorize.net

Acknowledgements

Please read the following and agree by checking the boxes below:

I acknowledge this registration form is a way for me to start the full application for retreat; it is *not* the full application required by teen and parent (if teen is under 18).

I acknowledge that submitting this registration form does not guarantee me/my teen a spot on the retreat.

I will check my email (and spam folder) upon this submission. If I haven't received an automatic confirmation email, I will email registrar@inwardboundmind.org to follow up.

Calculated Fields

Description fields

Authorize.net Fields

Authnet_Hidden_Fields

Contact Information