Form – Non-Residential Meditation Retreat Non-Residential Retreat Registration Form Step 1 of 3 33% Welcome to the online application form. Please note that all questions with an asterisk must be completed for your form to be accepted. Carefully fill out the form and do not omit anything. You will receive an e-mail acknowledging receipt of your application upon successful completion of this form. If you have any physical or emotional challenges that might make full participation in the retreat difficult, please speak to one of the teachers before completing the application. Retreat*Type of Retreat*Start Date* YYYY MM DD End Date* YYYY MM DD Location*Personal DetailsName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* Enter Email Confirm Email Additional InformationWhere did you hear about this retreat?Do you receive e-mail notifications of S.I.M.T. retreats?YesNoIf you have particular questions or concerns that you would like to share with us, please note them:If you wish to be informed of upcoming retreats and teachings, please sign up for our newsletter. Prior to the retreat, please review the retreat guidelines on our website. Payment DetailsWhen would you like to pay?*Now (with my credit card)At the door (cash, cheque, or money order only)Retreat Cost - 0.5 day*Non-Residential Retreat Registration FeeRegularSIMT SupporterRetreat Cost - 1 day*Non-Residential Retreat Registration FeeRegularSIMT SupporterRetreat Cost - 2 day*Non-Residential Retreat Registration FeeRegularSIMT SupporterRetreat Cost - 3 day*Non-Residential Retreat Registration FeeRegularSIMT SupporterRetreat Cost - 2019*Non-Residential Retreat Registration FeeRegularSIMT SupporterTotal FeeThe following total will deducted from your credit card if you pay now. If you choose to pay at the door, please ensure you bring this amount with you. $ 0.00 CAD Credit Card American ExpressMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name CAPTCHANameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.