RetreatRegistration-Credit-Debit

Retreat Registration Form
Your place on the Retreat is not
secured until you complete all
portions below, plus the final
registration page (see link below)

*All items with an asterisk are
required fields *

Location & Dates of Retreat you are registering for *:

Full Name *

Email *

Phone Numbers*

*If you are receiving psychiatric care or counseling please give reasons. If not then PLEASE WRITE N/A.

*Please list all medications you are
taking, prescribed or over the
counter. Write in box below
Please do not list vitamins, herbs,
natural products.
WRITE N/A if not applicable

*Please give your reason for taking each medication listed
previously in box to the left.

Please include the benefits you have seen, if any.

WRITE N/A if not applicable

PLEASE READ THIS PARAGRAPH BEFORE CHECKING ITEMS BELOW

By checking the following , you are stating , "I understand that I am committing to a personal growth journey.
It is common that at some point before or during the event, I may experience inner turmoil or resistance. This
is the result of an old sense of self becoming aware of an impending change to its identity. For many, this is
not conscious; and shows up as wanting to avoid the next step. It is quite human. For this reason, I
understand that Dr. Conlan requires the following “Agreements”. I also understand that Dr. Conlan limits the
class to 14; and due to rearranging his schedule, along with the cost of putting on the retreat , any
cancellations within 6 weeks of the event puts duress on him. In addtion, I recognize that this makes for a
shorter amount of time for preparation for another participant should there be a replacement available .":

I Agree with the points of the above paragraph

I DISAGREE with the points of the above paragraph

I Agree to Attend All of Retreat Part One-Fri 3:15-9:30pm// Sat. 8:15am-9:15pm// Sun. 8:15am-6pm:
Or if attending an In-residence retreat then Fri 2:30-9:30pm// Sat.6:30am-9:15pm// Sun. 6:30am-6pm

I Do NOT AGREE

I Agree

I Agree to Be On Time For the Entire Retreat. PLEASE NOTE :
You must be in your seat No Later Than 3:15 Friday or you may be turned away with no refund.:
Or if attending an In-Residence retreat then no later than 2:30pm Check-In on Friday

I Agree

I Do NOT AGREE

I Agree to Forfeit 100% of Course Fee if Cancelled within 1 month of Retreat:

I Do NOT AGREE

I Agree

I Agree to Forfeit 50% of Course Fee if Cancelled within 6 weeks of Retreat:

I Agree

I Do NOT AGREE

I agree to forfeit 10% admin fees if cancelled at any time prior to the retreat.

I Agree

I Do NOT AGREE

I agree to respond to all emails regarding this course in a timely manner

I Agree

I Do NOT AGREE

I Agree to do the Meditation Practices in Questionaire (Instructions on the link in the next question):

I Agree

I Do NOT AGREE

I Agree to Complete a Questionaire w/in 2 days of this Registration. Your registration and space is not
confirmed until this step is complete and you have sent your responses to Dr.Conlan's assistant (her
info is on the linked page), within 2 days. PLEASE COPY THIS LINK NOW and paste it in your INTERNET
BROWSER when you have completed this registration page and clicked 'SUBMIT' below .. .
http://www.NetworkSpinalAwakening.com/welcome2retreat.html

I Do NOT AGREE

I Agree