Please complete all information.

How did you learn about the program?
Metta Flyer Metta Website Email Workshop Metta Graduate Advertisement (where)
Other (describe):

Personal Contact Information

Affiliated Organization Information (if applicable)

End-of-Life Care/Counseling Experience

In what capacity do you currently serve the dying? As a:
Professional
Volunteer
Family Caregiver
Other (describe)

How long?

In what setting:
Hospice
Hospital
Home care
Other (describe)

Describe (frequency, place, role):


Current work or study:
Current professional title:
Years in professional practice:

Please list type and dates of any training you have received in end-of-life care, psychotherapy, coaching, spiritual direction, communications training, or other counseling modalities:

Spiritual Tradition/Inner Work

Do you currently have what you would describe as a "spiritual path"?
Yes No
How would you name it?
Years of practice in this tradition?

Do you have a contemplative or meditation practice?
Yes No
Please name your specific spiritual practice(s) and frequency (i.e. church one a week, daily chanting, one hour daily meditation)

Health Concerns

(If you prefer to discuss this by phone, please let us know.)
Do you have any significant physical health concerns or medical conditions that could impact your participation?
Yes No
If Yes, please describe:


Do you have, or do have you ever had, any mental health concerns such as depression, anxiety, addictions, or other psychiatric conditions?
Yes No
If yes, please describe

How Do You Plan To Apply Your Training?

Briefly describe how you will utilize the training:

In Your Professional/Volunteer Work? ( i.e. private practice, healthcare setting, educational institution, community organization)


In Your Personal Life? (i.e. family caregiver, spiritual development, educational training)

Retreat Experience (Check boxes that apply )

First Meditation Retreat
Completed 2-3 day Meditation Retreat.
Completed 7 day or longer Meditation Retreat.

Logistics

Preferred Occupancy: (Check boxes that apply)
Commuter
(commuters will only be accepted after all residential places have been filled)
Shared Occupancy
(Name of requested roommate )
Single Occupancy (when available for additional $100 cost)

Dietary Restrictions: (check all that apply)
None
Vegetarian
No Dairy
No Wheat
Other (specify)

I Can Attend the Entire Retreat (Friday, August 12 2011 at 5:00 p.m. to Wednesday, August 17, 2011 at 12:00 p.m.)