Refuge & Relaxation: BIPOC Young Adult Retreat

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Inward Bound Mindfulness 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@inwardboundmind.org | (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 genders are you comfortable sharing a room with?

What genders are you comfortable sharing a bathroom with?

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

What is their name?

What is the name of the studio or group?

What internet search term did you use?

Where did you find the ad?

Which social media service?

Inward Bound email or someone else's?

What magazine?

Where did you hear about this retreat?

Emergency contact during the retreat:

Emergency contact name:

Emergency contact phone:

Are you a college student?

YesNo

Name of college/university you attend

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

Ways you identify

Why do we ask for this information? 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 folks who 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 check all that apply to you:

LGBTQIA+	Neurodiverse
Disability	I self identify in other ways

Do you require any accommodations for your disability?

Please describe how you self-identify:

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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, describe below:

Tell us a bit about yourself in a few sentences.

What is your motivation for coming on this retreat?

Are you currently in therapy?

YesNo

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)?

Do you have interest in carpooling to the retreat?

We will arrange a shuttle service from the airport to the retreat center if more than two participants require transportation. The cost of the shuttle will be shared among those who utilize it, and the final cost per person will be determined based on the total number of riders. We will inform you as early as possible of the shared cost once we have the final count of participants needing the shuttle service.

Please acknowledge that you have completed this application form in its entirety. (The next page is the payment page.)

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

Payment Details

We aim for this retreat to be as accessible as possible, so we're offering three pricing tiers:

Scholarship Tier: $300 [limited available - 0 remaining]
Choose this tier if you require financial assistance to attend.

Sustainer Tier: $400
Choose this tier if you can cover the full cost of your participation on retreat.

Supporter Tier: $500
Choose this tier if you would like to contribute to our scholarship fund, directly supporting other young adults to attend retreat.

A deposit of $100 is required to reserve your place. Online payments are securely processed through our Authorize.net payment gateway. Full payment of your tuition amount is due by September 25.

Please specify your payment.

Sustainer Tier: $400Supporter Tier: $500

Deposit required to reserve your place

$

Please select current payment amount

Pay depositPay full tuition

Credit Card Details

Current payment amount

$

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 Inward Bound's operation costs.

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

All transactions are securely processed through Authorize.net

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Cancellation Policy:

If you cancel by September 18, your payment will be refunded minus the deposit. We cannot offer refunds for cancellations made on September 19 or after, because of our commitment to the retreat center. There is no refund if you decide to leave the retreat early.

Confirm that you have read and agree to our retreat cancellation policy above

I have read and agree to the cancellation policy for this retreat.

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Retreat Payment Amount: $

Credit Card Processing Fee: $

Total Current Payment: $

Authnet_Hidden_Fields

GA Tracking Code

Family member or friend	Member of the Inward Bound community
Yoga or Meditation Studio or Group	Internet Search
Internet Ad	Social Media
Email	Magazine Ad
Other