APPLICATION FOR
residential Retreats

Please read all the information on the workshop description page closely before completing the form below.

To help us evaluate your application, please answer all the required questions thoughtfully.

Retreat name

Please enter the title of the retreat you're applying for.

Retreat start date

Please enter the start date of the retreat you're applying for (for clarity, since sometimes we have more than one of the same type of retreat in a given year).

ABOUT YOU

Name

First Name

Last Name

Please type it carefully to be sure it's correct or we won't be able to reach you.

Your mobile phone number

In case of emergency or last-minute communications. (We respect your privacy.)

Country

(###)

###

####

Age

Gender

female

male

other, or prefer not to say

Pronouns

If you'd like to specify your preferred pronouns, you're welcome to do so here.

Address

Your legal residential address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Nationality

Passport info (for those who are not US citizens)

If you are NOT a citizen of the US, please enter your passport number, country, date of expiry, and place of issue.

Have you been to Earthville Institute before? If so, when and for what purpose?

Tell us something about you. Who are you and what do you care about?

What are your main interests, passions, and values? Who do you aspire to be? What do you aspire to do with your life?

ABOUT YOUR INTEREST IN THE RETREAT

Why are you interested to join this retreat?

Please give a thoughtful and detailed response here. What attracts you to this retreat? What kind of experience are you hoping to have? What is it that you hope to learn and take away from it?

Have you done any other programs similar to this? If so, what and where?

Any meditation or yoga retreats, or similar experiences? If so, what types and duration, and in any particular practice tradition?

Contemplative practice experience

Please give us a sense of your prior experience, if any, with contemplative practice. For example, do you meditate or practice yoga? If so, how regularly, and for how long?

Prior formal training, if any

Have you studied meditation, yoga, or other contemplative practices under a teacher or within any particular tradition? If so, please share details so we can have a sense of your prior practice training, if any. (Note: prior training is not required. It's just helpful for us to be aware of a participant's contemplative education background.)

Are you able and committed to stay for the full duration of the retreat?

Additional comments

Anything else you'd like to tell us?

GENERAL INFO

Food allergies and/or dietary preferences

We serve only healthy, mostly-organic, plant-based (vegan vegetarian) cuisine. We also do our best to accommodate special needs within our limited capacity, so if you are diabetic or have food allergies, gluten intolerance, etc., please let us know so we can do our best to take care of you.

Emergency contact

Provide the best person to contact in case of emergency. Please enter the name, phone number, email address, and relationship (e.g. mother, husband, friend). If you'd prefer to give us this info when you arrive, that's OK too, but we prefer to have it just in case.

Do you have any injuries, medical conditions, or other health concerns?

Any medical information will remain confidential. Please do inform us fully as it is our responsibility to be aware in case of emergencies. Do you have any allergies or sensitivities? Any physical limitations such as difficulty sitting or walking, back pain, etc.? Any other health issues? If yes to any of the above, please give details.

Mental and emotional state

This information will remain confidential. Please let us know if you have had any prolonged struggles with mental or emotional well-being. (Your response is for our retreat facilitators only. Please answer honestly, as it is our responsibility to be aware.)

Medications

Are you currently taking any medications, or have you recently stopped taking any medications? If so, which medications, and for what purpose? (Your answer will remain confidential, but we do need to know in case of emergency.)

How did you come to know about Earthville Institute? (Check all that apply)

A friend who has participated in Earthville program(s)

A friend who had heard or read about Earthville

Search engine (Google, etc.)

Instagram

Facebook

Other

Name(s) of person(s) who told you about Earthville Institute

If someone told you about Earthville Institute, what is that person's name?

Just one more step:

After you click the "submit" button below, your application will be sent to us for review. Follow-up questions and/or an online interview are often part of the application process. After we have reviewed your application (normally within 1-2 weeks), we will send you an email that will notify you of your application status (e.g. pending interview, pending receipt of deposit payment, waiting list, etc.).

APPLICATION FORresidential Retreats

Please read all the information on the workshop description page closely before completing the form below.

To help us evaluate your application, please answer all the required questions thoughtfully.

APPLICATION FOR
residential Retreats