* - required

Please fill out the form below for each person in your family who will be attending. Your privacy is important to us. This information will not be conveyed to any third party outside of the Dzogchen Shri Singha organizations.

You are registering for One-­Month Dzogchen Buddha Path Internship. It starts on Friday July 3rd, 2015 and concludes on Tuesday August 4th, 2015. The Internship fees are $3,000 USD.

DiscountsIf you qualify for discounts, please indicate below. Note that two types of discounts can be combined.
—Please choose an option—Child Discount ~ for those 12 and under years of ageTeens Discount ~ 150$ for those 13­-19 years of ageStudent Discount ~ 5% for those 20 to 25 years of ageSenior Discount ~ 100$ for seniors 65 and over
International Travel Discount ~ $300 for those who are flying to the retreat from outside North America

Age Group *Select your age group.
—Please choose an option—Senior (65 and up)Adult (19-64)Teens (13 to 18)Child (12 and under requires special permission of Internship Director)

First Name *Your personal name

Last Name *Your family name

Street *Street address or post office box

UnitApartment, suite or unit number

City *Or town

State *Or province

ZIP *Or postal code

Country *Or nation

Email *

Phone *Please enter your cell or another telephone number where we can reach or leave messages for you prior to the retreat.

Family ContactProvide the name of at least one family member or friend who won't be attending the retreat, along with their phone numbers, in case of emergency.

Refuge Vows *Have you taken Refuge Vows with an authorized Buddhist teacher?
—Please choose an option—I took refuge with Dzogchen Khenpo Choga Rinpoche.I took refuge with a Dzogchen Lineage Bodhisattva.I took refuge with a teacher in another Buddhist lineage.I have not taken refuge vows.I don't recall.

Refuge Vows TeacherIf you answered "Yes" to the question above, please enter the name of the Buddhist teacher who gave you Refuge Vows.

Refuge NameIf you've taken Refuge Vows, please enter your refuge name.

About the Medical Questions that Follow

For the safety of yourself and others, and in case of medical emergency, please respond to the following important health questions.

The retreat organizers aspire to maintain a healthy and safe environment for all retreatants. However, each individual is responsible for his or her health care during the retreat. This includes having an adequate supply of prescription medications, using them as prescribed and immediately reporting to the retreat director any health issues as they arise during the retreat.

Any misuse of prescription or over-the-counter drugs, or any possession or use of illicit drugs, alcohol or tobacco will not be tolerated. There is no smoking anywhere on the property. Violators will be dismissed immediately.

The information gathered in the three questions below will be kept confidential and will only be used to provide the retreat staff with the knowledge to appropriately respond in the event of an emergency.

Addiction Recovery *Have you ever been, or are you currently, in recovery or rehabilitation for addiction to alcohol, drugs, or any other substances? If so, list the recovery program type and explain your current status. If you have no addiction issues, please type, "none."

Health Issues *Do you have any health issues that will require ongoing maintenance or special health care during the retreat, for example related to: life threatening allergies, chronic physical or mental health conditions, heart conditions, blood pressure, thyroid, insulin, wheelchair access, etc. Please briefly explain all significant conditions and ongoing treatments. If you have no health issues, please type, "none."

Medications *Please indicate if you currently on any prescription medications, and if so, list the medications. If you are taking no medications, please type, "none."

Physician ContactPlease list your primary physician's name and phone numbers in case of a medical emergency.

Internships *Choose from the list the total number of Dzogchen Lineage Internships from which you have graduated.

Internships AttendedPlease check each of the Dzogchen Lineage Internships you completed and were awarded a certificate.
2008 – 3-month Internship2008 – 6-month Internship2009 – 2-month Internship2009 – 3-month Internship2010 – 1-month Internship2010 – 3-month Internship2010 – 6-month Internship2011 – 1-month Internship2011 – 2-month Internship2011 – 3-month Internship2011 – 2-month Internship Moscow2012 – 1-month Internship2012 – 3-month Internship2013 – 1-month Internship2013 – 3.5-month Internship2014 – 1-month Internship2014 – 3.5-month Internship

Other Retreats AttendedIf you have not graduated from an Internship, then please list all of the retreats you attended that were guided by Dzogchen Khenpo Choga Rinpoche. You may also list other retreats you've attended.

Certainty *How certain are you that you will attend this retreat?
—Please choose an option—Very certain I'll attendGood chance I'll attendNot certain, but I wish to

Special ConditionsDescribe any other special needs you have or make a note of any conditions or comments you’d like the organizers to read.

How Learned?Please let us know all the ways you learned of this retreat (for example: via an email newsletter, announcement at Buddha Path Practice, saw an online ad, found out through a web search, etc.).

PledgePlease consider contributing to the Retreat Fund that will make possible purchase of special supplies for the retreat and scholarships to pay the retreat fees for people in need. Your contribution will generate great merit for you and help accomplish our goal of decreasing and eliminating negativity for the benefit of all beings. Please enter the $ U.S. dollar amount you wish to pledge. Please include this donation when you pay your retreat fees. Retreat fee payments are not tax deductible, but your donation to this fund is tax deductible to the full extent of the law:

VolunteerA focused "Volunteer Days" program will be conducted during the days and weeks leading up to the Internship. You are invited to come volunteer for one or more days to help with the numerous projects we'd like to complete before the Internship starts. Our volunteers make a donation of $20 per person per day to help cover their share of food and utilities. You should plan to participate in morning and evening group practices. If you are able to volunteer, please describe your availability and the skills you can provide.

QuestionsIf you have any other questions or comments for the Internship Director, you may enter them below and we will respond to them on the registration web site. We may also contact you by phone or email to answer any urgent or private questions. The organizers are unpaid volunteers, so your patience with us is much appreciated!

Birthday *In particular, if your birthday falls during this event, please let us know the month and day so that we do something to acknowledge your special day.
—Please choose an option—12345678910111213141516171819202122232425262728293031—Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Agreement *Carefully review your answers above, make a note your total fees due adding any pledge you may have made, and then click the "Register" button below to record your registration.
I have read the Dzogchen Lineage Internship Retreat Overview above and agree with the all policies stated there.