Peaceful Mind, Happy Heart – The Four Sublime Mind States and You (Program Only)

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1 Welcome

Guest 1		First Name* Last Name* Email* Gender
Guest 1		First Name* Last Name* Email* Gender

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Address
Address 2
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Emergency Contact Info	Please provide a name and phone number
Starting on which day do you plan to be in silence?
Dietary *	Please choose the dietary option above that applies to you. Please select Omnivore if you have no restrictions.
Severe Medical Food Allergy #1 *	Please specify your severe food allergies. We aim to meet the following dietary needs: Gluten Free, Dairy Free and Vegetarian. If you have particular dietary needs – we suggest you bring special food to support your experience. Feel free to contact guest services to discuss guestservices@bethlehemcentre.com
Do you require wheelchair accessible accommodations?	This could include other mobility aids (i.e. walker, shower chair).
Do you need ground floor accommodation? *
Program Comments or Special Needs	Please describe any special needs you have such as: Certified support animal(s), mobility needs, CPAP machine hookup, etc.
Birth Date
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How did you hear about us?
Email newsletter	Please send me the email newsletter
Age	25 & under 26-35 36-55 56-75 76+
Cancellation Policy *	I accept the terms and conditions.Please read the terms and conditions
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