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  • DZOGCHEN CENTER RETREATS

    Registration for the Summer Dzogchen Meditation Retreat with LAMA SURYA DAS

    Saturday July 21 to Sunday July 29, 2012 Garrison Institute, Garrison, New York

    Dzogchen Center

    General Information (Please print legibly) Name Male Female

    Address

    Phone Day Preferred

    Evening Preferred

    Email

    Occupation

    Reservation (Select a room)

    $1295

    Private Room

    $995 Double Room (one roommate)

    $795 Multiple-Occupancy Room

    Deposit or full payment is enclosed

    $400 deposit or Full registration fee If the full registration fee is not paid, a reminder of the balance due will be sent three weeks prior to the start of retreat and that balance will be due, either by credit card online or by check, to arrive at Dzogchen Center within the following 7 days. Please see below for cancellation policies.

    Form of payment (in US dollars only)

    Check or money order

    VISA MasterCard Account Number

    Name as it appears on card Expiration Date

    In the event you cancel more than one month prior to the start of the relevant retreat, your deposit will be refunded in full less processing fee of $50.

    In the event you cancel less than one month prior to the start of the relevant retreat, your deposit will be carried forward (less processing fee of $100) as an available credit toward registration fees for another Dzogchen Center retreat prior to (but not including) the same retreat in the following year.

    If neither payment in full nor notice of cancellation is received by Dzogchen Center at least 7 days prior to the start of retreat, any deposit or credit will be forfeited.

    PO BOX 400734 CAMBRIDGE, MA 02140 USA 585-348-7125 RETREAT@DZOGCHEN.ORG WWW.DZOGCHEN.ORG

  • SUMMER 2012 DZOGCHEN MEDITATION RETREAT WITH LAMA SURYA DAS PAGE 2

    Practice and Retreat Experience

    If you have participated in other Dzogchen Foundation retreats, please indicate those below:

    If not, please provide a brief summary or your practice and retreat experience:

    Health/Special Needs or Requests (Please answer all questions carefully and completely)

    Do you have any current medical difficulties of which we should be aware? Yes No If yes, please specify

    Are you currently taking any medication? Yes No If yes, please specify

    Have you had any major difficulties in previous retreats? Yes No If yes, please specify

    Are you in therapy? Yes No (If yes, please be sure to discuss your intention to do this retreat with your therapist.)

    Please list any other special needs or requests.

    Any other comments?

    Emergency Contact

    Name Relationship

    Address

    Phone Day

    Evening Thank you for your registration

    Please Sign Date

    We will confirm your reservation and provide additional information upon receiving this form and payment. Please mail this form with your deposit (credit card details on this form or check enclosed) to:

    Dzogchen Center Retreats PO Box 400734 Cambridge, MA 02140 USA

    If paying by credit card, for faster service you may instead fax this form to +1 (949) 606-8469

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