IH2022 Retreat Registration Beyond Distraction with Shaila Catherine

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Registration
This form takes approximately 20 minutes to complete. You may download the PDF version of this registration form to preview the questions. It is best to complete and submit the form in one sitting. There is no guarantee that you can return to the survey with your responses saved if you quit halfway.
Note: This will be a non-smoking retreat. Vaccination to prevent COVID is required.
Name*
First Last
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone Numbers: Work
Home
Mobile
Occupation*
Age*
How did you learn about this retreat?
Emergency Contact: Name*
Phone*
Relationship*
Experience
This retreat is designed for experienced students. Previous retreat experience in the insight meditation tradition is required, with a minimum of at least one week-long silent residential retreat. If you do not have the required experience, your attendance requires approval from the teacher.
Have you previously attended a retreat with Shaila Catherine?*
- Yes
- No
Is this your first residential retreat?*
- Yes
- No

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Retreat
Please list the dates of previous retreats you have attended that were taught by Shaila Catherine.*
Please describe your experience with other meditation retreats. Approximately how many silent residential retreats have you attended, what is your longest retreat, and in what traditions?*
Please describe any other practices or retreats that have a significant impact on your meditation practice.*
Please describe any psychological conditions or life changes that might make meditation practice difficult at this time (such as anxiety, panic, depression or other mental health conditions requiring medical treatment, grief, recent loss, recent change of job, recent marriage or divorce, psychological illness, drug addiction, alcoholism, etc.). If you are experiencing intense emotional states, please check with your therapist to determine if this is an appropriate time for you to undertake an intensive silent retreat. We recommend that only those who are experiencing a considerable degree of mental stability consider attending this retreat. We ask that students who have used mind-altering or hallucinogenic drugs within the last two years (including plant-based ceremonial substances) refrain from attending this retreat.*
This will be a silent retreat environment. Retreatants need to be at ease with both silence and solitude. Silence is required, and participants are asked to remain on the property during the course of the retreat and refrain from all contact with people outside the retreat. This means no use of cell phones, smart phones, or Internet, no texting, e-mail, or any other form of communication except in the case of an emergency. There will be group and/or individual meetings with the teachers. Participants are expected to periodically communicate with the teachers at these scheduled meetings. Do you agree to keep the silence in the retreat, refrain from using electronic communication devices, and communicate with the teachers at designated times?*
- Yes
- No
If no, please explain. If you anticipate needing to communicate with family or anyone outside of the retreat, please indicate below or inform the registrar or teachers.*
Are you willing to take the following precepts and abide by them during the retreat?*
During the retreat, we vow to abide by the five precepts, which are:
1. To abstain from killing and harming living beings (This includes all beings, both human and otherwise.)
2. To abstain from stealing or taking what is not given
3. To abstain from sexual misconduct (On retreat, we abstain from all sexual activity.)
4. To refrain from false, malicious, or harsh speech (On this retreat, we will maintain silence except when functional speech is required during work meditation and meetings with the teacher(s).)
5. To refrain from using intoxicants (This includes drinking alcohol, smoking, and using recreational or mind-altering drugs. Note that this is a non-smoking retreat, which prohibits the use of traditional as well as e-cigarettes.)
- Yes
- No
We maintain a dress code that is casual but discrete. The guidelines are the same for males and females. You should be covered from shoulders to knees—no shorts (unless they are long enough to cover the knees when sitting) and no revealing shirts. Are you willing to abide by this dress code during the retreat?*
- Yes
- No
Is there anything else you would like the teacher to know that might help them guide your practice during this retreat?

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References
Applicants are not always able to accurately assess their readiness to attend intensive group retreats, and we do not have staff resources to support special psychological needs. Therefore, we now require newcomers to Bodhi Retreats to provide two referrals from established meditation teachers, recognized sangha leaders, or previous participants of Bodhi Retreats. We may contact one or both of your references to verify that they perceive you as a mature, emotionally stable, suitable candidate for this intensive silent retreat. Please provide two references here.
Name of personal reference #1*
Role or affiliation (such as meditation group that they lead, organization where they teach, association with a meditation community etc.)*
Your reference’s location (City/State/Country)*
Your reference’s email*
Your reference's phone number*
Name of personal reference #2*
Role or affiliation (such as meditation group that they lead, organization where they teach, association with a meditation community etc.)*
Your reference’s location (City/State/Country)*
Your reference’s email*
Your reference’s phone number*
Medical Needs
Do you have any medical needs or mobility limitations?*
- Yes
- No
Please describe any medical needs, mobility limitations, physical limitations, or injuries that would prevent you from doing sitting and walking meditation, or require special accommodation, or affect the performance of a basic chore/yogi job. Indicate if you have any environmental sensitivities that might affect room assignments. If you have mobility limitations, please contact our retreat registrar for details about accessibility.*
Would you have difficulty ascending one flight of stairs or wish to request a room that is accessible without stairs?*
- Yes
- No

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Teacher Dana
Registration fees cover only food, accommodations, and basic administrative expenses. There will be an opportunity to offer donations/dana at the end of the retreat to support the teacher(s).
Scholarship
Would you be willing to help those who need financial assistance to attend the retreat?
- Yes
Amount of your donation to the scholarship fund:

Please include your scholarship donation when you send your deposit or fees to the registrar. Scholarship contributions made via checks payable to “IMSB” or to “Insight Meditation South Bay” will be tax deductible. Please write a separate check for your donation to the scholarship fund if you wish to have it tax deductible. Write “B-R scholarship” on the memo line.
To request scholarship assistance, please email the registrar.
Deposit/Retreat Fee
How do you intend to pay the deposit/retreat fee?*
- Zelle transfer
- Mail a check
- Contact the registrar for alternative payment options (available only if the above two options are not possible)

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By entering my full name below, I confirm that all of the above information is correct to the best of my knowledge, and I acknowledge that I have considered my psychological condition and have determined that it is appropriate for me to undertake this retreat. I have read and agreed with an affirmative response to abide by the guidelines to maintain silence, keep the precepts, and respect the dress code. I understand that attendance is at the discretion of the teacher, and I agree to depart if requested by the teacher, and to bear any and all costs involved in an early or unexpected departure.*

Full Name

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WAIVER OF LIABILITY. VOLUNTARY PARTICIPATION - 1. I acknowledge that I have voluntarily applied to participate in all or part of the meditation retreat sponsored by Bodhi-Retreats and/or Insight Meditation South Bay that will be held August 29-September 8, 2022, with an optional early arrival date of August 28, 2022 and an optional late departure date of September 9, 2022. ASSUMPTION OF RISK - 2. I am aware that participating in this event may involve strenuous physical activities such as work meditation, yoga, or movement classes; risks associated with hiking, including contact with poison oak and wildlife; and because this event is a group activity, the risk of being exposed to the COVID-19 virus, even though precautions will be taken to prevent exposure. I am also aware that this is a silent, intensive meditation retreat and that participants in such retreats may experience intense and unusual psychological, spiritual, and/or physical states arising from the meditation and associated retreat activities. I am voluntarily participating in these activities with full knowledge of the risks involved, and hereby agree to accept any and all risks of harm that may result from these activities. RELEASE - 3. As consideration for being permitted by Bodhi-Retreats and/or Insight Meditation South Bay, or one of its affiliates to participate in these activities and use their facilities, I hereby agree that I, my assignees, heirs, distributees, guardians, and legal representatives will not make a claim against, sue, or attach the property of Bodhi-Retreats, Insight Meditation South Bay, its affiliates, employees, agents or volunteers or any of its affiliated organizations for injury or damage resulting from acts, howsoever caused, by any employee, agent, volunteer, or contractor of these organizations, or any of their affiliated organizations, as a result of my participation in this event, except when an employee, agent, volunteer, or contractor of Bodhi-Retreats or Insight Meditation South Bay or any of its affiliated organizations exhibits gross negligence, or intentionally acts in a manner likely to lead to my being harmed. I hereby release Bodhi-Retreats and Insight Meditation South Bay, and any of its affiliated organizations from all actions, claims or demands that I, my assignees, heirs, distributees, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my participation in this event, except when an employee, agent, or contractor of Bodhi-Retreats and Insight Meditation South Bay, or any of its affiliated organizations exhibits gross negligence or intentionally acts in a manner likely to lead to my being harmed. KNOWING & VOLUNTARY PARTICIPATION - 4. By ENTERING MY FULL NAME BELOW, I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract between myself and Bodhi-Retreats and/or Insight Meditation South Bay, and/or its affiliated organizations, and sign it of my own free will.*
Full Name
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- Third Choice
Comments
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Practical, Relevant, Profound

Step 1 of 7

Registration

Experience

Retreat

References

Medical Needs

Teacher Dana

Scholarship

Deposit/Retreat Fee

Guidelines for Preventing the Spread of COVID-19

Rides

Diet

Retreat Option

Partial Retreat

Ignatius House Accommodations, Bedding, and Towels

Title

Interview with Shaila on the Escaping Samsara Podcast

How to Focus – Listen to Shaila Catherine on 10% Happier

Podcast on Teaching Meditation and the Relationship of Jhana and Insight.

Listen to Shaila’s interview on Wisdom Dharma Chats

How conduct bears fruit – a talk on the precept of not-killing.

Joy of Seclusion

Strengthening Concentration – Shaila speaks at Dhamma Center