Personal Retreat Application Form

• Please Note: Before booking a Personal Retreat, you need to have completed at least 2 weeks 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 Personal 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

  You can use the Personal Retreat Cost Calculator to calculate the cost of your proposed retreat.

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• Contact Details

• First name*
• Last name*
• Email*
• Phone*
• Additional Phone
• Address*
  Address line 1 Address line 2 Town/City County Post code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe
• 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 Details

• Requested Retreat Dates

  We can only accept applications until the end of 2019 (and not into the following year).

• From:*
  (the day you arrive)
• To:*
  (the day you leave)

• Booking and Cancellation Conditions

  Payment and Deposits:

  • Retreats up to and including 3 nights: Please pay in full at the time of booking.
  • Retreats of 4 nights or more: A non-refundable, non-transferable deposit of £100 will secure your place. Please pay the balance at least one month before the start date.
  • If you have paid a deposit, an email will be sent to you to remind you to pay the outstanding balance.
  • If you have not paid in full, one month before the start of your retreat, your place may be cancelled (with the loss of your deposit), and offered to someone on the waiting list.

  Cancellation and Refunds:

  • If you cancel more than 1 month before the start date of the retreat, the cancellation fee will be £100.
• Please note that the Sponsor rate includes a non-refundable donation and is refunded at the Standard rate.
• If you cancel less than 1 month but more than 2 weeks before the start date, the cancellation fee will be £100 or half the cost of your retreat, whichever is greater.
• Extra nights cancelled more than 1 month before your arrival date will be refunded, less a £20 admin fee.
• Extra nights cancelled less than 1 month in advance will be charged in full.
• If you cancel less than 2 weeks before the start date, the cancellation fee will be the full amount paid.

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.

• 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*
• Do 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 your 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

• Food Policy

  Gaia House offers a healthy, balanced vegetarian diet that may include eggs and dairy produce.

  • Vegan, dairy-free and wheat/gluten-free options can be requested when you register on arrival.
  • 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. You can request the Simple Diet when you register on arrival.

  If none of the above options meet your dietary needs, or you have a medical need for a different diet, please contact our Retreat Manager, Susanne O’Brien, on retreatmanager@gaiahouse.co.uk before booking your retreat.

  Food Allergy/Sensitivity:

  • We always label dishes containing any allergens you have told us about.
  • Whilst on retreat, please speak to a member of the Gaia House team for more information on allergens in our dishes.
• I confirm:*
  • I have read the Food Policy and am aware of the dietary options
• Keep in touch with Gaia House:
  Please tick your preferences. Your details will not be shared with anyone. About Privacy.
  • Email: I'd like the bi-monthly Gaia House e-news, other news, activities and fundraising appeals by email
  • Post: I'd like the annual newsletter and programme, other news, activities and fundraising appeals by post
  • Phone: I'm happy for you to contact me about your news, activities and fundraising appeals by phone

• 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 Period: Personal Retreats at Gaia House include a daily one-hour 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:*
• 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: Personal 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? 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 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)