retreat application: step 1 of 2

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retreat application: step 1 of 2

Here is Step 1 of your application. Please fill out this form and pay the $35 application fee. Upon submission, you will receive an email with a unique link to complete Step 2 of your application.

Note: you are not signed up for retreat until you complete Step 2. 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

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

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

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

Select a payment method

credit cardcheck

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

The $35 application fee is non-refundable.

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, 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 form is Step 1 of 2 for submitting my application.

I acknowledge that submitting this Step 1 form does not guarantee me/my teen a spot on the retreat. I need to complete Step 2 via the link in my inbox to reserve my spot.

I will check my email (and spam folder) after submitting this form. If I haven't received an email with a link for Step 2, I will email registrar@inwardboundmind.org to follow up.

Calculated Fields

Description fields

Authorize.net Fields

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Contact Information