ERRC Private Retreat Application Form

Heart Chan
East Regional Retreat Center

987 Shenendoa Drive, Ellijay, GA, 30540
herrc@heartchan.org

Application for Private Retreat

This application must be filled out completely for anyone planning to have a private retreat at the East Regional Retreat Center (ERRC).  Please do not make any travel plans until you have received a written approval for your request from ERRC management.

Please include a copy of your driver's license or government issued identification card with a photo.  Your application will not be reviewed without the requested ID card.

All information provided is for Heart Chan/ERRC management to make decision and for emergency purposes only and will be kept confidential.


Basic Information

Name:*
Address:*
Phone:*
-
E-mail:*
Fax:
-
Sex:*
Age:*
Are you a current Heart Chan member?*
If yes, which center/group do you belong to?

Driver License/Identification Card Information:

Number:*
State of Issurance*
Expiration Date*
 / 
 / 

Proposed Arrival/Departure Date and Time:

Arrival Date:*
 / 
 / 
Arrival Time:*
 : 
Departure Date:*
 / 
 / 
Departure Time:*
 : 

Please describe your past experiences in meditation/spiritual practices:

Types of meditation/spiritual practices you've done before
Length of time you practiced
Additional information you would like to share about your past practices:
Have you attended any retreat at ERRC before?*
If yes, when?
Daily work practice is required while staying at ERRC. Please list work skills you have (for example, computer, kitchen, gardening, construction, writing/editing, etc.)

References

Please list two references (not close relatives).  One should be a current or recent employment supervisor.

Reference 1

Name (R1)*
Address (R1):*
Phone (R1):*
-
E-mail (R1):*
Relationship (R1):*
How long has this person known you? (R1)*

Reference 2

Name (R2):*
Address (R2):*
Phone (R2):*
-
E-mail (R2):*
Relationship (R2):*
How long has this person known you? (R2)*

Emergency Contact

Please list the person to be notified in case of emergency.

Emergency Contact 1

Name (E1):*
Address (E1):*
Phone (E1):*
-
E-mail (E1):*
Relationship (E1):*

Emergency Contact 2

Please list your next of kin if that person is not the emergency contact listed above:

Name (E2):*
Address (E2):*
Phone (E2):*
-
E-mail (E2):*
Relationship (E2):*

Health Information

Are you covered by health insurance?*
Name of insurance company:
Insurance I.D. Number:
Do you have allergies to any food or medication?*
Please list the food/medication you're allergic to:
Have you ever been diagnosed with any physical or psychological conditions that we or a doctor should know about or would require special accommodations? *
If yes, please describe the condition(s) (optional) and/or required accommodations:
Have you ever been arrested or convicted of a crime? *
If yes, please describe what and when:
Do you have any additional information you would like to share with us that has not been covered?

I have read and understand Heart Chan/ERRC's polices, rules, and regulations. I agree to adhere to these polices, rules, and regulations should I be accepted for my visit. I understand that failure to do so may result in the termination of my visit.

I acknowledge that all the information included in this application is true and complete.  I authorize Heart Chan/ERRC management to contact any of the individuals listed above to support this application and give permission for Heart Chan/ERRC management to do a criminal background check, using all information included in this application, with agencies from this state or any state or federal agency, to the extent permitted by the state and federal law.

Please print your name here to acknowledge and sign this document:*
Date:*

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