Racism in America Participation Form
" indicates required fields
State / Province / Region
Antigua and Barbuda
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Congo, Democratic Republic of the
French Southern Territories
Heard Island and McDonald Islands
Isle of Man
Korea, Democratic People's Republic of
Korea, Republic of
Lao People's Democratic Republic
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
South Georgia and the South Sandwich Islands
Svalbard and Jan Mayen
Syria Arab Republic
Tanzania, the United Republic of
Trinidad and Tobago
Turks and Caicos Islands
US Minor Outlying Islands
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Emergency Contact Name
Provide the Name of your Emergency Contact Person
Emergency Contact Phone
Provide the Telephone Number for your Emergency Contact Person
21 or younger
22 - 30
31 - 40
41 - 50
51 - 60
61 - 70
71 - 80
81 - 90
91 - 100
Please choose your preferred pronoun.
Prefer not to answer
Name you prefer to be called:
Which selection best matches how you self-identity?
Please Choose (Drop-Down)
Prefer not to answer
Religious/Spritual Affinity or Affiliation
Please choose the religious/spiritual affinity group(s) that most resonate with you.
Native American Spirituality
Prefer not to answer
Not listed (Click here and note below)
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?
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.
Retreat Fee: $750.00 (USD)
The registration fee of $750 (USD) covers the bus transportation between Selma and Montgomery and all museum fees. Attendees are responsible for travel costs to and from the retreat, and all lodging and meal costs while in Selma and Montgomery. Attendees are also responsible for making their own hotel reservations.
What motivated you to participate in this retreat?
How did you hear about this retreat?
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.
Please note the following important dates for the cancellation and refund policy. All refunds are normally processed within 60 days of the notification of cancellation. 1) If the retreat is canceled by Zen Peacemakers International (ZPI), the retreat fee will be fully refunded. 2) If it is canceled by the registrant before March 20th, 2023, the fee can be refunded after the $100 administrative fee is deducted. 3) If it is canceled by the registrant between March 20th and April 15th, 2023, the fee can be refunded after a $300 cancelation fee is deducted. 3) The Retreat Fee becomes non-refundable if it is canceled by the registrant on or after April 15th, 2023. IMPORTANT NOTE: The participants are responsible for their own hotel reservations, cancellations, and related fees/penalties.
I understand and will comply with the cancelation policy.
We support our attendees’ concern for security and safety and we require all those registering to provide a photo image of each Covid vaccination card to be emailed to firstname.lastname@example.org by April 1 (no later than April 15). We will, of course, follow the COVID regulations in place at the time of the retreat onsite as well. Every country may have different regulations and types of certificates needed for entry/exit/re-entry at different times. For example, some countries currently require proof of testing negative 72 hours prior to re-entry. This may change; however, participants are asked to be aware of the regulation updates and be prepared. Please be advised that the testing fees are not included in the retreat fees. Although costs will be covered personally, we will assist in making this service accessible.
I understand and will upload a photo image of my Covid vaccination card at this time.
I understand the requirement and will submit the proof of vaccination by April 1, 2023.
I have previously submitted my proof of COVID Vaccination.
Vaccination Card Image(s)
Drop files here or
Max. file size: 50 MB.
We Look Forward To Hearing From You
Please add our email address (email@example.com) to your email address book or contact list to prevent our communications from going into your Spam/Junk Folder.
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.
This field is for validation purposes and should be left unchanged.