Harvard Spring Break Retreat

Page 1

This retreat is ONLY for students enrolled at Harvard University.

iBme will keep confidential all information provided in this application except as required for participation in the Retreat or as otherwise required by law.

Questions? registrar@ibme.info | (508) 250-0628

First Name

Last Name

Email

Phone

Outside U.S.?

Street Address

City

State

Province/State

Zip/Postal Code

Country

Date of Birth (MM/DD/YYYY)

What is your gender?

What pronouns do you use? (Why do we ask this?)

Please list your pronouns

What is your dorm preference?

MaleFemaleGender Expansive*

*In order to ensure that we are providing an environment that feels safe and welcoming for all young adults, we offer a gender expansive/non-binary dorm option on each retreat. Young adults who do not feel comfortable in either a male-identified or female-identified dorm are welcome to sleep in this space.

Ways You Identify

Why do we ask for this information? We are committed to diversity and we want to know more about you and how your lived experiences contribute to your unique identity so we can better support all participants. Sharing the various ways that you identify also helps us to communicate and share with the wider world the diversity of teens that attend our retreats, and that all are welcome. Some of this information will be collected for data (without your names or personal info) to share with donors and other supporters who want to know the broad impact our retreats have.

What race/ethnicity do you most identify with?

Please describe how you self-identify:

Do you require any accommodations for your disability?

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

YesNo

Mailing list text

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.

Emergency contact during the retreat

Emergency contact name:

Emergency contact phone:

House (if college student) or Graduate school program (if graduate student)

Please indicate any special dietary requirements you want us to know about:

Page 2

All fields are required. If a field does not apply please write N/A.

Please list dates of any previous meditation retreats you have attended - please include teacher names and tradition:

If you have a current daily/weekly spiritual/meditation practice please describe below:

Have you been in therapy in the last year?

YesNo

Please describe your experience in therapy (diagnosis, treatment, dates):

Have you ever been psychiatrically hospitalized?

YesNo

If so, when?

Have you ever had or been treated for a psychological condition such as depression, eating disorder, drug/alcohol addiction, anxiety disorder, psychosis, schizophrenia, mania or any other psychological condition?

YesNo

Please specify condition(s) and date(s):

Are you currently taking medication for any psychological conditions?

YesNo

Please specify the condition and list the medications and dosage:

Are there currently conditions in your life which may be placing you under stress, or which might make meditation difficult for you at this time (e.g. recent loss of a loved one, substance abuse/withdrawal, relationship ending)?

Are there any additional comments or information you would like to convey to the teacher(s)?

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

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

Page 3

The fee for this retreat is $50

The fee is non-refundable, and any cancellations received after February 20th will incur an additional $50 cancellation fee.

Please select your method of payment:

By credit cardThis fee is a financial hardship and I request assistance.

Payment Acknowledgment

I understand that this tuition fee is not refundable and that any cancellations received after February 20th will incur an additional $50 cancellation fee.

Credit card details

All online payments are securely processed through our Authorize.net payment gateway.

Billing First Name

Billing Last Name

Billing Email

Credit Card Number

Expiration Month

Expiration Year

Card Verification Value (CVV / CSC)

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

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

Scholarship requested

Please note if you request financial assistance, your application will be "pending" until we can verify your financial aid status

Harvard U ID#

Authorization

I authorize Harvard College to share limited information about my level of financial need with the Center for Wellness, in order to determine my eligibility for a waiver of the program participation fee.

Current Payment

Payment amount fields

Current Retreat Payment: $

Credit Card Processing Fee: $

Total Current Payment: $

Hidden fields

Credit card

Retreat info

Authorize

Authnet_Hidden_Fields

GA Tracking Code

heterosexual	LGBTQIA+
neurodiverse	person of color
person with disability	white/causasian
I self identify in other ways