Pacific Hermitage Retreat Registration Form - Birken Forest Buddhist Monastery (Sītavana)

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Personal Information & Contact Information

Retreat Dates*

Please indicate the retreat dates you are confirmed for.

Name*

First

Last

Email Address*

Phone*

Age*

Gender:*

Mailing Address

Street*

City*

Province/State

Postal Code/Zip

Country*

Emergency Contact

Name, phone number, and/or e-mail address of emergency contact. This should be someone that you are NOT travelling with.

Contact Name*

Contact Phone

Contact E-mail

Accommodation & Special Needs

Is this your first visit?*

Yes

Room Request*

Main Guest House

Kuti (Cabin with no electricity/running water/flush toilet)

Please note that kutis are rarely available. Most guests will be assigned to the main house. Particular room requests inside the main guest house are not permitted. We ask all guests to accept whatever accommodation is provided with a sense of contentment and gratitude.

Do you snore?*

Yes

Don't know

Do you have any serious medical condition?*

Yes

Please tell us about any conditions that might affect your participation in the monastery schedule, activities, guidelines, adherence to the Eight Precepts, etc.

If YES, please give brief details.*

Please let us know if your condition is controlled by medication, stable or unstable. We also need to know if it is likely to cause you a problem while you are here and whether you anticipate needing any kind of special support during your visit.

Do you suffer from any kind of mental illness?*

Yes

Please tell us about any conditions that might affect your participation in the monastery schedule, activities, guidelines, adherence to the Eight Precepts, etc.

If YES, please give brief details.*

Have you had any recent problems with drugs or alcohol?*

Yes

If YES, please give brief details and confirm whether you have been abstinent from drugs/alcohol for at least six months.*

Additional Information?

If you have any additional information that you would like us to know, please list it here.

Guest Guidelines

The Birken Guest Guidelines can be found here.

I have read the Birken Guest Guidelines*

Yes

I agree to abide by the Eight Precepts while I am a guest at the monastery*

I agree to abide by the Eight Precepts

I agree to abide by the Seven Precepts, but have a medical need for food in the evening, identified below

I would like to request a non-food related exception from the Eight Precepts, explained below

If requesting an exception from the Eight Precepts, please provide more details*

All guests must abide by the Eight Precepts during their stay at the monastery. In exceptional cases (e.g. if you have hypoglycemia or diabetes), you may request an exception from the Eight Precepts to have a light evening snack. These exceptions must be approved by the Abbot prior to your visit and will be acknowledged in your booking confirmation.

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