Madre Grande Monastery

A Sacred site for healing, teaching, ceremony, and celebration

Register For A Retreat

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                                                                              Application for Spiritual Retreat

 

Name _____________________________  Date_________________

Address ________________Date of Birth___________________

City __________  State ____  Zip ___________  Country ________


Phone _________________________________  Email _______________________________

Occupation(s)________________________________  Work Phone(s)____________________

Emergency Contact __________________________Phone ____________________________

When do you wish to begin? (Please pick two dates)_____________________________________

Why do you wish to retreat at Madre Grande Monastery? (Attach another sheet if necessary)_______________________________________

_________________________________________________________________________________________________________________

Pick a retreat purpose from our website:

___________________________________________________________________________________________________________

Our Requirements:

No special accommodations needed                                  No Pets

Have your own transportation                                             No Drugs, Alcohol or Smoking allowed                              

How did you hear about us? ____________________________________________________

Medical Information

For your safety and the safety of others, we kindly ask you to answer the following questions to the best of your ability. (If you have privacy concerns, please contact the registration office at (619)-468-6869.

Allergies
Please describe any allergies you may have____________________________________________________________________

Physical Health History
Please describe any on-going medical conditions you may have_____________________________________________________
Medication for Physical Health
Please list any medications you may be taking for any physical health reason____________________________________________
Mental Health History
If you have ever sought psychological counseling, please describe the circumstances______________________________________
Mental Health Diagnosis
If you have have been diagnosed with a psychiatric or psychological disorder, please explain_________________________________
Medication for Mental Health
Please list medication prescribed for any mental health diagnosis, and indicate which medications you are currently taking.___________
Doctor's Name____________________________
Doctor's Telephone Number__________________

                   Madre Grande Monastery

              Headquarters of The Paracelsian Order
       2260 Lucky Six Truck Trail, Dulzura, CA 91917

                      Phone / Fax: (619) 468-6869

                   reservations@madregrande.org

                           www.madregrande.org

                             Tax ID: 33-0195480

To submit an application, download the application form in Word format, fill it out, and email it back to us as an attachment using the form at the bottom of the page or print and mail it.  Or copy and paste the form below to your word processor or suitable app and email it back to us as an attachment, or print and mail it.