Work Retreat Application form Step 1 of 4 0% Please Note: Before booking a Work Retreat, you need to have completed at least 2 weeks residential teacher-led, Insight (Vipassana) or Zen meditation retreat in silence (either as two separate weeks or one continuous retreat of 14 days), not necessarily at Gaia House. All Work Retreat Application forms will be submitted to a Gaia House teacher for approval. Applications from people who do not have sufficient previous experience will be refused. If you have any questions before you apply, please call Reception: +44 (0)1626 333613 Contact detailsFirst name* Last name* Email* Phone* Additional Phone Address* Address line 1 Address line 2 Town/City County Post code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Your Personal information The information you disclose in relation to your booking is used specifically in relation to the retreat you are applying for. This form is kept in both electronic and paper formats up to and throughout your stay. Your information is encrypted whilst being transferred from the website to our systems. The information is used by teachers and other members of staff, as required as part of their duties. Once your retreat has been completed your electronic form will be deleted and your paper form shredded. Your application will also be deleted if your application is declined or subsequently cancelled. A record of your retreat dates will be held on our database. For further information on how we treat your information please read our Privacy Statement.Booking detailsRequested Retreat Dates All retreats start and finish on a Sunday and are for a minimum of two weeks duration.From:*(the day you arrive) DD dash MM dash YYYY To:*(the day you leave) DD dash MM dash YYYY HiddenPlease confirm that you are in the UK for 14 days prior to the retreat dates.* I will be in the UK for 14 days prior to my retreat dates. Providing a safe environment coming out of the pandemic*Before booking, please read our current covid guidelines. I have read and understood the covid guidelines. HiddenPrior to my arrival at Gaia House, I understand that if I am requested to self isolate, I will inform Gaia House and forego my place on the retreat. I will inform Gaia House of any self-isolating requests. If, unfortunately, you need to self-isolate over the time you would have been attending your retreat, your retreat will be cancelled and you will be offered a full refund.HiddenNHS Test and TraceDuring your retreat we request that you check your mobile regularly in case there are any relevant NHS messages. If during your stay at Gaia House you are requested to self-isolate we ask that you let one of the residenital team know. If we are contacted by NHS Test and Trace, we are obliged to inform them of your contact details. I will check my mobile once a day during the retreat. If I receive a request to self-isolate whilst at Gaia House I will inform a member of the residential team promptly. I understand Gaia House will pass my details to NHS Test and Trace if requested. HiddenThere will be protocols around the use of showers. I agree to adhere to the additional protocols around the use of showers. HiddenRoom allocation I understand single rooms will be pre-allocated and Gaia House will consider requests in relation to medical needs and health conditions. HiddenTemperature check I give consent to my temperature being taken on arrival at Gaia House. I understand that if my temperature is 37.8c or above on arrival I will not be able to stay and my retreat will be cancelled, with a full refund offered. HiddenEmergency planning I have made arrangements to leave Gaia House by car in the event that I have symptoms of the virus. HiddenPlease describe your plans to leave Gaia House in the event of a positive lateral flow test:Deposit and Booking Fee: Work Retreats must be paid for in full at the time of booking. Cancellations and Refunds for confirmed Retreat places: The Booking / administration fee is non-refundable. The Deposit is refunded on satisfactory completion of your Work Retreat. The Deposit is NOT refunded if you cancel the booking or do not complete the Work Retreat for the dates agreed with this application. Refunds have to be authorised by the Finance Department and can take up to 5 working days to be processed. Please note that cancellations can only be accepted from the named retreatant and not from third parties. Cancellations can be made by phone or email. Cancellation fees (less administration costs) are placed in the Financial Assistance and Bursaries Fund (FAB Fund). Booking conditions may be subject to alteration. See: Booking and Cancellation.I confirm:* I have read and agree to the booking & cancellation conditions Personal details This helps us to arrange appropriate accommodation. Gender* Female Male Another Gender Identity Additional information (optional)You are welcome to provide additional information if you would like to. Our Retreat Manager will contact you via email to discuss your accommodation needs. Any information you provide is confidential and will only be used in support of your retreat.Date of birth* DD slash MM slash YYYY Have you attended a work retreat at Gaia House in the last 5 years?* Yes No Dietary and food policy Gaia House offers a healthy, balanced plant-based diet. Wheat/gluten-free options can be requested on arrival. At lunch we also offer a ‘Simple Diet’ consisting of a gluten-free wholegrain, steamed vegetables and plain pulses, egg or tofu. This diet is intended to meet nutritional needs whilst being as plain as possible. The simple diet, including protein choices, can also be requested on arrival. If you have a medical need for a different diet, please contact the kitchen manager. Read our food policy here. food checkboxes* I understand the food policy offered Keep in touch with Gaia House:Your support sustains Gaia House’s Dharma offerings and we’d love to keep in touch with you, sharing our news, activities and appeals. Please tick your preferences. If you already receive our information, there is no need to opt-in again. Your details will not be shared with anyone. About Privacy. Email: I am happy to hear from Gaia House by email Post: I’m happy to hear from Gaia House by post Practice Information This information is strictly for the confidential use of teachers and staff on a need to know basis. Please answer these questions fully to enable the teachers to guide your retreat appropriately. Disclosure of any physical/psychological history will not necessarily prevent you from undertaking a retreat. Please state 'no' or 'none' to any questions that don't apply. Work retreatants are allocated according to the needs of the house, and need to be able to work in any department. Do you have any limitations that may affect your capacity to work?*Work retreats often involve work that is strenuous and physically demanding, so you need to be fit and in robust good health. Please be aware that some departments involve being able to do some heavy lifting. Please tell us of any skills you have.E.g. maintenance, gardening etc.Do you have any special needs that we need to be aware of?E.g. allergy, disability, long-term illness or health condition.Retreat experience: Gaia House is a silent retreat environment for sustained meditation practice. Retreatants need to be experienced and committed to both silence and solitude. Please list all silent meditation retreats you have undertaken, their duration and the teachers with whom you have practised:*If the list is extensive, please state this with a summary and list only your most recent retreats.Retreat intentions: What are your intentions regarding your meditation practice during your time on retreat? Which particular styles of meditation do you intend focusing on?*Retreat support: Work retreatants staying longer than 1 week: Interviews will be offered twice a week with one of the Gaia House Teachers, is this sufficient support for you?*References: If your retreat is for longer than a month please send a reference (if possible) from a meditation teacher with whom you have previously practised or provide his/her contact details. Physical & psychological history Please note: A difficult psychological history and present will not necessarily prevent you from being accepted for this retreat. However, we do need to feel confident that you have the capacity and resources to be self-supporting in the silent retreat environment. Please state 'no' or 'none' to any questions that don't apply. Physical health: Do you have any history of physical illness or any disabilities, which may significantly affect your sitting, standing or walking practice?*Mental health issues: Have you ever been diagnosed with or experienced any significant mental health issues? If yes, please give details of condition(s) and date(s).*Eg. depression, eating disorders, anxiety, drug/alcohol abuse etc.Have you ever attempted to take your own life? If yes, please indicate date(s).*Mental health support: If you are involved with mental health services and have a community psychiatric nurse, psychiatrist or support worker please provide their name and phone number.*Stress: Describe any current circumstances which might be placing you under stress or may significantly affect your meditation practice:*E.g. bereavement, redundancy, relationship breakdown etc. Medication: Are you taking any medication for any physical or psychological condition? If yes, please give details of condition and medication.*Is there any additional information you would like to convey to the teacher(s)?Emergency contact details Please give details of someone we can contact in the event of an emergency.Emergency contact name* Emergency contact phone number* Other emergency contact information:We very much look forward to welcoming you to Gaia House. It is important to us to be truly inclusive and welcome all people. We invite you to contact our Reception team if you want to tell us more about how we can welcome you: Email info@gaiahouse.co.uk or call 01626 333613.I agree to take full responsibility for myself during this retreat. I understand that all retreatants need to observe the practice guidelines and that retreats at Gaia House are undertaken and continued with the agreement of the teacher.*Retreatant Signature (please type in your full name in lieu of a signature) Δ
