Padma Samye Ling Registration Form

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PSL WWOOF Application

* These fields are required

1 Please tell us about yourself...

2 Choose the dates of your stay

3 Your Information

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 Info

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

Please describe any meditation history, teachers you've studied with, and your current occupation *
Do you have any health concerns we should be aware of? If so, please elaborate *
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

8 Security Check