Padma Samye Ling Registration Form

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PSL Learning Dharma Skills Program Application

* These fields are required

1 Please tell us about yourself...

2 Dates

3 Learning Dharma Skills Application

Guest 1		First Name* Last Name* Email* Gender* Gender is asked in order to help coordinate accommodations. Shared dormitories are arranged with a floor for women and and a floor for men. Please know we welcome and support everyone. If you identify as non-binary/gender fluid then please check the location you are most comfortable with. Please feel free to contact us if you have any questions or concerns. Birth Date*
Guest 1		First Name* Last Name* Email* Gender* Gender is asked in order to help coordinate accommodations. Shared dormitories are arranged with a floor for women and and a floor for men. Please know we welcome and support everyone. If you identify as non-binary/gender fluid then please check the location you are most comfortable with. Please feel free to contact us if you have any questions or concerns. Birth Date*

4 Participant Information

Address
Address 2
City
State/Prov.
Zip/Postal
Country
Phone *
Are you working with any mental health concerns right now? Please share as openly and honestly as possible so we can know how to best support you. *
Have you been formally diagnosed with any mental health issues? *	Yes No
Please provide details *
Have you ever been hospitalized for mental health reasons? *	Yes No
Please provide details *
Are you currently taking any psychiatric medications?* *	Yes No
Please provide details *

5 References

6 Talents & Experience

7 Additional Information

Why are you interested in the learning Dharma Skills Program and what are your Goals?
Please describe any meditation history, teachers you've studied with, and your current occupation *
Are you a regularly contributing member of Padmasambhava Buddhist Center? *	Yes No
Which PBC temple do you send membership dues to? *	PBC New York PBC Florida PBC Puerto Rico PBC Tennessee Thanks for your on-going support! In order to apply your PBC Member discount, enter "PBCmember10" as your discount code in the "Contributions" section of this form..
Gender *	Gender is asked in order to help coordinate accommodations. Shared dormitories are arranged with a floor for women and and a floor for men. Please know we welcome and support everyone. If you identify as non-binary/gender fluid then please check the location you are most comfortable with. Please feel free to contact us if you have any questions or concerns.
Birth Date *
Comments or Special Needs	Let us know if you have any additional comments or needs.
Email newsletter	Please send me the email newsletter
Security check *	Type the text shown:

8 PBC runs entirely based on donations, if you can contribute to the program we suggest a sliding scale from $25 to $475 per month.

9 Make your contribution

	By submitting payment, you authorise Padmasambhava Buddhist Center to send instructions to the financial institution that issued your card to take payments from your card account in accordance with the terms of Padmasambhava Buddhist Center's agreement with you.