30 Days meditation retreat 2022 | Québec, Canada

October 16th to November 16th 2022

Application for 2022 retreat

How many days?
Name
Email
Gender


Age
Address
City
Province/State
Country
Phone
Have you been in a retreat with Beth?


If yes, then in which year and for how long?
Have you ever participated in any other meditation retreat? Please list the number of days you attended the retreat, year, method and the teacher’s name.
Do you meditate at home? If yes, how often do you sit and for how long?
How did you hear about this retreat?
Do you have any mental/psychological problem? If you do, please list.
Do you suffer any physical illness? chronic health issue? Please list if you do.
Do you need to take medications daily? If so, please list the most important ones that you can’t go without, the doses and how many time per day.
Do you have a primary physician? If you do, please list his/her phone number in case of medical emergency.
Emergency contact: please list the person’s name, his/her phone number, and relationship to you.
Do you have allergy to egg, wheat gluten, or any other food allergy? Please list.
Any comment? Special Request?