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Living Fearlessly with Change – Application Form

Please note that the 2016 course is currently full. However, if you are interested in participating we encourage you to complete an application form and we can add you to the waiting list, in case any places become available.

Name and Contact Details

First Name *
Last Name *
Address *
Town / City *
County / State
Post Code
Country *
Email Address *
Telephone Number *
Additional Telephone Number

Booking Details

Terms & Conditions

Payment and Deposits:

  • If your application is successful we will register you on the course and contact you to pay a deposit to secure your place. This deposit is non-refundable.

I have read and agree to the Terms & Conditions *

Personal Details

Gender * FemaleMale
Year of Birth - e.g. "1980 *
Have you attended a retreat at Gaia House in the last 5 years? * NoYes


On retreat the food offered will be a healthy, balanced vegetarian diet that may include eggs and dairy produce.

Vegan, Non-Diary, Wheat/Gluten-free, and Simple Diet options can be provided on request. (The Simple Diet option consists of a grain, steamed vegetables and plain pulses, egg or tofu, and is intended to meet nutritional needs while being as plain as possible.)

Gaia House is not able to cater for other dietary needs which differ from these options.

Food Allergy/Sensitivity:

  • While cooks will endeavour to label any 'problem' ingredients, we cannot guarantee to do so. We cannot label the ingredients of soups or left-overs at tea-time.
  • Retreatants with a severe allergy should opt for the Simple Diet.
  • If there is a medical necessity, it may be possible for you to bring your own personal supplies at the discretion of the Kitchen Coordinators. Please phone before booking.
  • We are not able to store meat or fish on the premises

If you have concerns that your needs cannot be met through this stated policy, then please get in touch with Reception before continuing with your booking on or 01626 333613.

I have read and accept the Food Policy and am aware of the dietary options. *


Group Retreat accommodation is usually in shared rooms. If you need a single room because of disability, poor health or age, please give reasons to help us allocate appropriately. We regret single rooms cannot be guaranteed as we have a limited number, but we will do our best to accommodate according to needs.

Single Room Request

I would like to request a single room, and understand that this cannot be guaranteed

I would like a single room if possible
Reasons for requesting a Single Room

Practice Information

The purpose of this application form is to assess whether your experience and intention would support your undertaking this 10 month course of Buddhist meditation, contemplation, practice and service. Please answer every question as fully as you can.

The three retreats for this course will contain periods of silence and sitting meditation practice, participants therefore need to be committed to engaging with silent practice.

In order that we can get a clear picture of your experience and current practice, please tell us about it:

1a. What is your current meditation practice, for example - mindfulness of breathing, body, insight meditation - etc? *
1b. Is there any tradition that you primarily practise in? If so, what? *
2a. How regularly do you practise meditation and how long have you practised for? *
2b. Describe your personal meditation practice over the last year: *
3. Please list any meditation retreats you have undertaken, their duration, approximate dates, and the teacher(s) with whom you have practised. *
4a. The themes for this course include exploring and reflecting on ageing, illness and death, if you have previous experience in any of these areas, be it in voluntary or paid work, or as a carer for a family member or friend, please tell us about it: *
4b. If not engaged in this sort of service already, are you able to commit to 2 hours of voluntary work each week in these areas for the duration of the course? * I can commit to 2 hours of service either through my work, a volunteer role or caring for a friend or relative.
5. What is your intention for taking this course, what inspires you about it? *
6. Are you able to commit to: *

- Developing a regular meditation practice of at least 15 minutes a day (or more) at least 4 times a week.

- Spending between 1 - 2.5 hours a week engaged in: reflecting on a variety of themes, listening to dharma talks, being available on a Sunday late afternoon, for a live video conference call, being part of an on-line discussion group.

- Attending 3 residential retreats over a 10 month period.

If you have any reservations about whether you have the experience needed to engage with this course of study and practice, please contact us.
I can commit to these requirements

Physical and Psychological History

Whatever information you reveal in this part of the form is not intended to exclude you from taking part in the course, but rather to see if there is any additional support you may need.

Do you have any history of physical illness or any disabilities, which may significantly affect your sitting, standing or walking practice? *
Have you ever been diagnosed with or experienced any significant mental health issues e.g. depression, eating disorders, anxiety, drug/alcohol abuse? If yes, please give details of condition(s) and date(s). *
Are you taking any medication for any physical or psychological condition? If yes, please give details of condition and medication. *
Have you ever attempted to take your own life? If yes, please indicate date(s) *
If you are involved with mental health services and have a Community Psychiatric Nurse, Psychiatrist or Support worker please provide their name and telephone number. *
Describe any present circumstances which might be placing you under additional stress or may significantly affect your meditation practice (e.g. bereavement, redundancy, relationship breakdown etc) *
Is there any additional information you would like to convey to the teacher(s).

Emergency Contact Details

Name & Telephone Number(s) of someone we can contact in case of emergency: *
I agree to take full responsibility for myself during this course. I understand that all retreatants need to observe the practice guidelines and that retreats are undertaken and continued with the agreement of the teacher(s).
Participant Signature (please type in your full name in lieu of a signature)

Either Zohar or Jean (the teachers) will contact you to talk through your application with you.

* = required