Retreat Cabins
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2
Price
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$15.00
– Non refundable application fee
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3
Participant Info
Requested Retreat Start Date
Jan
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1931
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1924
Retreat start and end dates must fall on a Monday or a Friday.
Retreat End Date
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
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2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
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1931
1930
1929
1928
1927
1926
1925
1924
Preferred Name
Please note our system will automatically use your legal first name in communications, but we will make every effort to address you by your preferred name during a retreat
Gender
*
--SELECT--
Male identify
Female identify
Gender Fluid
Gender Non-binary
Occupation
Date of birth
*
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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31
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
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1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1941
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
Cell Phone
*
Address
*
Address 2
City
*
State/Prov.
*
Other/International
Alabama
Alaska
Alberta
Arizona
Arkansas
Australian Capital Territory
British Columbia
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New South Wales
New York
Newfoundland
North Carolina
North Dakota
Northern Territory
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Quebec
Queensland
Rhode Island
Saskatchewan
South Australia
South Carolina
South Dakota
Tasmania
Tennessee
Texas
Utah
Vermont
Victoria
Virginia
Washington
West Virginia
Western Australia
Wisconsin
Wyoming
Yukon Territory
Zip/Postal
*
Country
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United States
Canada
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire (Ivory Coast)
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Democratic Republic Of Congo (Zaire)
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guinea
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard And McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Kitts And Nevis
Saint Lucia
Saint Vincent And The Grenadines
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And South Sandwich Islands
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City (Holy See)
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (US)
Wallis And Futuna Islands
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Name of Emergency Contact
*
Relationship to emergency contact
Emergency Contact Phone Number
*
Emergency Contact Email Address
*
Emergency Contact Home Address
*
Address 2
City
*
State/Prov.
*
Other/International
Alabama
Alaska
Alberta
Arizona
Arkansas
Australian Capital Territory
British Columbia
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New South Wales
New York
Newfoundland
North Carolina
North Dakota
Northern Territory
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Quebec
Queensland
Rhode Island
Saskatchewan
South Australia
South Carolina
South Dakota
Tasmania
Tennessee
Texas
Utah
Vermont
Victoria
Virginia
Washington
West Virginia
Western Australia
Wisconsin
Wyoming
Yukon Territory
Zip/Postal
*
Country
*
United States
Canada
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire (Ivory Coast)
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Democratic Republic Of Congo (Zaire)
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guinea
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard And McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Kitts And Nevis
Saint Lucia
Saint Vincent And The Grenadines
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And South Sandwich Islands
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City (Holy See)
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (US)
Wallis And Futuna Islands
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Name of Emergency Contact #2
*
Relationship to Emergency Contact #2
Emergency Contact #2 Phone Number
*
Emergency Contact #2 Email Address
*
Emergency Contact #2 Home Address
*
Address 2
City
*
State/Prov.
*
Other/International
Alabama
Alaska
Alberta
Arizona
Arkansas
Australian Capital Territory
British Columbia
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New South Wales
New York
Newfoundland
North Carolina
North Dakota
Northern Territory
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Quebec
Queensland
Rhode Island
Saskatchewan
South Australia
South Carolina
South Dakota
Tasmania
Tennessee
Texas
Utah
Vermont
Victoria
Virginia
Washington
West Virginia
Western Australia
Wisconsin
Wyoming
Yukon Territory
Zip/Postal
*
Country
*
United States
Canada
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire (Ivory Coast)
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Democratic Republic Of Congo (Zaire)
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guinea
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard And McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Kitts And Nevis
Saint Lucia
Saint Vincent And The Grenadines
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And South Sandwich Islands
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City (Holy See)
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (US)
Wallis And Futuna Islands
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Do you give us permission to transport you to the nearest medical facility should you incur serious illness or injury?
*
Yes
No
If no, please indicate the name and contact telephone number of the physician or health care provider you would like us to contact in the event of an emergency
Health Insurance Coverage (Company/Policy #/Phone #)
*
Allergies (medicine, food, bee stings, etc.)
This information may be provided to any hospital or medical practitioner not having access to your medical history.
Medications currently taking
This information may be provided to any hospital or medical practitioner not having access to your medical history.
Date of last tetanus shot (good for 8-10 years)
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
This information may be provided to any hospital or medical practitioner not having access to your medical history.
Physical impairments
This information may be provided to any hospital or medical practitioner not having access to your medical history.
Other medical information
This information may be provided to any hospital or medical practitioner not having access to your medical history.
Driver's Licence, ID, or Passport
*
State/Country of Issue, License or ID Number, Exp. Date
How did you first hear about this program?
Tara Mandala Website
Tara Mandala Print Catalogue
Tara Mandala Direct Email
Google Search
Ad in Lion's Roar (print or online - please indicate below)
Ad in Tricycle (print or online - please indicate below)
Ad on Radio (please indicate the station)
Facebook Event Page
Facebook Ad
Google Ad
Bing (Microsoft)
Suggested by Tara Mandala Teacher
Suggested by Sangha Leader or Peer
Suggested by Lama Tsultrim
Magyu Zoom Call Announcement
Magyu Email Announcement
Are you a member of the Magyu, Gateway, or Ösel Nyingtig Program?
Magyu
Gateway
Ösel Nyingtig
I'm currently enrolled in more than one of the above-listed programs
not enrolled
Personal Retreat History: Please state where, when and for what length you have done personal/solitary retreat.
*
Additional Information
E.g. if you are a loud sleeper, name of person you would like to share a room with etc
Discount Code
Private Retreat Cost
3-5 nights $95/night, one week $400, 2 weeks $650, 3 weeks $900. 1-6 months $950/month, 6 months-1 year $850
Please describe in detail all current medical conditions
Have you ever been treated for mental illness?
yes
no
If you answered yes to the above question, please explain in more detail.
Do you have a history of suicidal tendencies?
yes
no
If you answered yes to the above question, please explain in more detail.
What is your planned daily schedule for this retreat?
Please write a detailed paragraph on your intention and plans for this retreat at Tara Mandala.
*
Who is your current teacher? Are they aware that you are doing this retreat?
Please add any additional comments here.
Email News
Please send me email updates from Tara Mandala.
Have you reviewed Tara Mandala's Visitor Release and Waiver of Liability? You will be required to sign this document in person upon check-in.
*
Yes
No
Click here to read Tara Mandala's Visitor Release and Waiver of Liability
Have you reviewed Tara Mandala's Assumption of Risk and Waiver for Covid-19? You will be required to sign this document in person upon arrival.
*
Yes
No
Click here to read Tara Mandala's Assumption of Risk and Waiver for Covid-19
Tara Mandala Terms of Use Agreement
Click here and READ OUR TERMS OF USE AGREEMENT
Terms of Use Agreement
*
I agree to the Terms of Use
Tara Mandala Privacy Policy
Click here and read our Privacy Policy.
Privacy Policy Agreement
*
I agree to the Privacy Policy
Tara Mandala Participant's Code of Conduct & Ethics Agreement
Click here and READ OUR PARTICIPANT'S CODE OF CONDUCT AND ETHICS
Participant's Code of Conduct & Ethics
*
I have reviewed and agree to Tara Mandala's Participant's Code of Conduct & Ethics
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4
Donate
Please enter your donation amounts below
$
Support Tara Mandala
Your generous contribution to our Annual Fund allows Tara Mandala Retreat Center to be a year-round center, a repository for wisdom literature, a center for translation, a beacon for the feminine in Buddhism, an active dharma center with weekly dharma study and practice that provides refuge for deep practice and transformation.
$
Give to Scholarship Fund
Please consider donating to our scholarship fund, which allows those that need financial assistance to attend our programs. Scholarships are awarded at 25% to 75% of program costs depending on need and situation.
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5
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usually a 3 digit code on back of card
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