November Solitary 2024 – Application Form Step 1 of 5 0% Before booking a place on the November Solitary month-long, you need to have completed at least 3 weeks teacher-led, Insight (Vipassana) or Zen meditation retreat in silence (these can be separate week retreats), not necessarily at Gaia House. Before booking for the two-week November Solitary, you need to have completed 2 weeks teacher-led (Vipassana) or Zen meditation retreat in silence (these can be separate week retreats), not necessarily at Gaia House. If you would like to apply for a two-week retreat but have less than three weeks' previous retreat experience, you are strongly encouraged to start your two-week retreat on 1 November. All Application forms will be submitted to a Gaia House teacher for approval. Applications from people who do not have sufficient previous experience will be declined. If you have any questions before you apply, please contact us. Name* First Last Email* Phone Number* Additional PhoneAddress* Address line 1 Town/City County Postcode 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 Country Do you wish to book on a retreat of two week duration?* Yes No The following rates for the month retreat are below, please indicate the rate you are wish to pay.*Please consider paying at the highest rate that you are able to. Your generosity is vital in supporting Gaia House to sustain its Dharma offerings for the benefit of all.Standard rate: £2,100Basic rate: £1,624Supported rate: £1,344Young persons rate: £487FAB fund rate: £812Which retreat period do you wish to apply for?*Please note that the retreats are for the full duration and we cannot accept early or late arrivals.1-15 November 202415-29 November 2024The following rates for the two week retreat are below, please indicate the rate you are wish to pay.* Please consider paying at the highest rate that you are able to. Your generosity is vital in supporting Gaia House to sustain its Dharma offerings for the benefit of all.Standard rate: £1,148Basic rate: £882Supported rate: £728Young persons rate: £265FAB fund rate: £441Do you need financial assistance to attend this retreat (FAB Fund)? We are committed to ensuring that our programme is available to everyone who wishes to participate. If our rates are too high for you, we invite you to apply for support from our Financial Assistance and Bursaries Fund (FAB Fund). If you require financial assistance, please tick the box below and a member of our team will contact you. I would like to apply for Financial Assistance Gaia House and covid-19*As the conditions and guidelines are changing, we are remaining flexible and will be reviewing what is needed at the time of each retreat. Prior to your retreat, we will send some more information about what to expect whilst at Gaia House. I have read the information on Gaia House’s coronavirus web page Room allocation:* I understand single rooms will be pre-allocated and Gaia House will consider requests in relation to medical needs and health conditions. Booking and cancellation conditions Please read our booking terms and conditions. I confirm:* I have read and agree to the booking & cancellation conditions Personal Details Gender* Female Male Another gender identity Additional information (optional)You are welcome to provide additional information if you would like to. Our Retreat Manager may 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*please remember to change the year!Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have specific needs relating to a disability or health condition?* No Yes 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 any support needs. Any information you provide is confidential and will only be used in support of your retreat.Have you attended a personal 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. 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 Work Period: Your stay at Gaia House will include a daily work period. Retreatants are allocated to a department according to the needs of the house. If you have any limitations which may affect your ability to carry out a work period, please give details:* 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. 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?* 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? e.g. depression, eating disorders, anxiety, drug/alcohol abuse? If yes, please give details of condition(s) and date(s).*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 via info@gaiahouse.co.uk if you want to tell us more about how we can welcome you.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
