Penn State Relational Mindfulness 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

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, we offer a gender expansive/non-binary dorm option on each retreat. Those who do not feel comfortable in either a male-identified or female-identified dorm are welcome to sleep in this space.

How did you hear about this retreat?

Emergency contact during the retreat:

Emergency contact name:

Emergency contact phone:

Are you an Undergraduate student at Penn State?

YesNo

Which Penn State college are you affiliated with?

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 with the wider world the diversity of those who attend our retreats, and that everyone is welcome. Some of this information will be collected for data (without your names or personal info) to share with donors who want to know the broad impact our retreats have.

What race/ethnicity do you most identify with?

Please check any 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:

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)?

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

I have completed this application in its entirety.

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Penn State Relational Mindfulness Retreat – March 7-10, 2026

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