Native American Bearing Witness Retreat Participation Form

Name*

First Last

Address*

City State / Province / Region Country

Email*

Mobile Phone*

Emergency Contact Name*

Provide the Name of your Emergency Contact Person

Emergency Contact Phone*

Provide the Telephone Number for your Emergency Contact Person

Age*

Select Range

Pronoun*

Please choose your preferred pronoun.

She/Her

He/Him

They Them

Prefer not to answer

Name you prefer to be called:

Racial Identity

Which selection best matches how you self-identity?

Religious/Spritual Affinity or Affiliation

Please choose the religious/spiritual affinity group(s) that most resonate with you.

If your religious/spiritual affinity is not listed above, please briefly describe:

Do you have any physical limitations that require special assistance during the retreat?

Please Describe

Accommodations

Upon Registration/Payment, you will have the opportunity to book accommodations. We have reserved a small group of single room cabins within the park. 4 Single Occupancy - 11 Double Occupancy - 3 Triple Occupancy. You may also choose to find your own accommodations (Camping is available and we suggest calling 1.800.710.2267 and speak with someone about availability). More details upon registering.

I Understand

I Don't Understand (we will contact you)

Are you currently undergoing psychotherapy, taking medication due to mental illness or have history of treating mental illness?

The context and nature of the retreat may invoke in some people various emotional responses. In order for the retreat staff to better understand your needs, prepare to support you, and determine the retreats' compatibility for you.

Please Describe

Retreat Fee: $895.00 (USD)*

The retreat fee finances the administrative and logistical costs of the retreat such as transportation, lodging, food, tour guides, and travel of staff as well as towards the year-long administration of the retreat by ZP staff. It contributes to honorariums and travel costs needed to bring select guests, scholarships for local participants, those of diverse backgrounds and those with limited means. Participants are responsible for all travel, lodging (including making reservations), and meals.

I understand

What motivated you to participate in this retreat?

How did you hear about this retreat?

Ethical Guidelines*

Bearing witness retreats often take us to places of deep suffering and even trauma. Participants are encouraged to bear witness not just to certain external and historical events, but also to personal issues of vulnerability and darkness. While the entire staff, including spirit holders, council facilitators, religious leaders and coordinators, tries to create a retreat environment that serves these goals, it is the responsibility of all of us, staff and participants alike, to maintain this environment for the sake of all participants. For this reason I agree to uphold this Code of Ethical Conduct, which is based on principles of trust, integrity, justice, respect and accountability, in order to nurture this bearing witness retreat.

I understand that this retreat provides an opportunity to practice the Three Tenets of the Zen Peacemakers: (1) Not Knowing, (2) Bearing Witness, and (3) Taking Action from Not Knowing and Bearing Witness.

>> Accountability. Maintaining the well-being of the retreat is the mutual responsibility of all participants. I agree to consciously cultivate a space where all voices and opinions are heard, the diversity of individual experiences is affirmed and encouraged, and where all participants feel safe in sharing personal shortcomings and concerns. Clear communication supports taking responsibility for both oneself and the retreat, and is thus an act of service to all participants.

>> Transparency. Transparency is crucial to maintaining balance and harmony. I will speak out on matters that, if left unaddressed, may foster doubt, suspicion or resentment.
Self-Awareness. Knowing that this retreat may be arduous to both mind and body, I will take responsibility for monitoring and caring for myself.

>> Right Speech. Mutual respect manifests when we treat each other with dignity and engage with everyone truthfully and compassionately. Harmony is promoted when I observe right speech: refraining from lies, self-serving talk, slander, or apportioning blame. It also includes proactively and skillfully speaking out in a manner that respects all persons involved. Recognizing the potency of anger, I will practice self-awareness and endeavor to express myself openly and generously, without blame or rejection.

>> Confidentiality. I understand that the retreat includes processes and procedures that may involve the sharing of sensitive personal information, and that this information should be held in confidence as much as possible. This caution particularly applies to staff members. On those occasions when, for the well being of specific individuals, staff members need to consult with each other, such consultations will be maintained in confidence.
Boundaries. I am responsible for clarifying, maintaining and communicating appropriate and clear boundaries with other participants.

>> Sexual Conduct. I acknowledge that sexuality is a highly vulnerable part of human experience, and even more so in retreats that challenge our bodies, minds and hearts. For this reason I will not form a new sexual relationship during the retreat with other retreat participants.

>> Use of Intoxicants. I understand that clarity of mind is a fundamental component of the practice of the three tenets. The use of non-medically prescribed intoxicants during retreats is acceptable only when prescribed by the retreat staff.

>> Practices Outside the Scope of the Retreat.All activities should support the purpose of this retreat as declared in the advertised description. No staff member or leader can give teachings or practices that lie outside its purview. Any doubts or questions about this should be taken to the spirit holders for resolution.

I agree to the Ethical Guidelines policy.

Cancellation Policy*

Please note the following important dates for the cancellation and refund policy. 1) If the retreat is canceled by Zen Peacemakers (ZP), the registrants will receive full refunds of the paid registration fees. If a registration is canceled by the participant before May 14th, ZP will refund all but a $100 cancellation fee to help cover administration expenses. 2) If a registration is canceled by the participant after May 14th but before June 15, ZP will refund all but a $300 cancelation fee to help cover administration expenses. 3) The retreat fee becomes non-refundable if a registration is canceled by the participant after June 15. 4) All refunds will be processed within 60 days of the notification of cancellation. IMPORTANT NOTE: If participants book their own accommodations, participants are responsible for their own hotel/camping reservations, cancellations, and related fees/penalties.

I understand and will comply with the cancelation policy.

We Look Forward To Hearing From You*

Please add our email address (retreats@zenpeacemakers.org) to your email address book or contact list to prevent our communications from going into your Spam/Junk Folder.

I Understand

Human Verification

For security reasons, please check on the "I'm not a robot" checkbox to complete the registration and protect our system from automated security breaches.

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