ERRC Retreat Application Form

Heart Chan
Sacred Light Mountain Retreat Center
(East Regional Retreat Center)

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


Application for SLM/ERRC 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.

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:*
Phone:*
-
E-mail:*
Other Contact Method (Wechat, Line, Facebook, etc.)
Sex:*
Are you over 21 years of age?*
Are you a current Heart Chan member?*
Which center/group do you belong to?
Do you have a valid driver's license?*
What are you applying for?*
List the purposes/objectives of your visit:
Proposed Arrival Date & Time:*
Proposed Departure Date & Time:*
Please describe your past experiences in meditation/spiritual practices, including type(s) of meditation/spiritual practices you have done, the length of time you have practiced, and any additional information you would like to share about your past practices:
Have you previously attended any retreats or teacher trainings at ERRC?*
If yes, please list the time (month & year) and type(s) of the event:
Daily work practice is required while staying at ERRC. Please list work skills you have (for example, computer, kitchen, gardening, construction, writing/editing, etc.)

Reference

If you are a Heart Chan member, please list your center leader/group leader/teacher as your reference. 

Name of the Reference:*
Center/Group/Area:*

Emergency Contact

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

Name :*
Phone :*
-
E-mail :*
Relationship:*

Health Information

Are you covered by health insurance?*
Do you have allergies to any food or medication?*
If yes, 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:

Other Information

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.  If any information provided in this application are misleading or false, I understand that Heart Chan/ERRC management has the right to remove me from the site immediately. 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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