[At Home] Jhanas, Satipatthana and Dependent Origination: An Online Retreat for Experienced Students

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1 Welcome

2 Sliding Scale

	$140.00 to $440.00 – Sliding Scale Pricing
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3 People in your group

Guest 1		First Name* Last Name* Email* Gender*
Guest 1		First Name* Last Name* Email* Gender*

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4 Supporter Contributions

Please choose the option that best fits your ability to give at this time. Any amount paid above the Base rate is a tax deductible contribution to Southern Dharma.

2026 No Supporter Contributions

Selecting this option will not add any additional cost to your registration fees. Note that registration fees do not include dana for the teacher(s).

$0.00

2026 Sustaining Supporter

This donation of an additional $70 per night makes it possible for Southern Dharma to bring another practitioner to the mountain.

$70.00

2026 Community Supporter

This supporter donation of an additional $120 per night supports Southern Dharma in bringing two additional practitioners to the mountain.

$120.00

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5 Participant Info

Phone *
Address *
Address 2
City *
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Email Newsletter	Please send monthly newsletter from Southern Dharma
Gender *
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Do you identify as LGBTQIA+ (lesbian, gay, bisexual, trans, queer, intersex, asexual, and beyond)? *
Do you identify as Black, Indigenous, or a Person of Color (BIPOC)? *	Yes No
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Birth Date *
Do you meet the minimum retreat experience requirements listed in the program description? If you do not you cannot register for this retreat. *
Do you have any medical dietary restrictions or food allergies? Vegan and gluten-avoidant can be accommodated. Southern Dharma CANNOT accommodate people who require a gluten-free facility. Other requests will be considered on a case-by-case basis. *	Please let us know if there are any sensitivities to specific foods. All meals are vegan with vegetarian options. Southern Dharma does not purchase or serve meat or fish.
Do you have any physical needs or limitations that might restrict your movement or your full participation in the retreat? *
Comments or Special Needs
Do you have any specific requests regarding your accommodations, including double room vs dorm, gender preferences, CPAP, etc.? *
Do you snore and/or use a CPAP? *
Emergency Contact Info (Name AND Phone Number) *
Is this your first meditation retreat? *	Yes No
Have you previously attended a retreat with Southern Dharma? *
I acknowledge that as a first time yogi at Southern Dharma, I must arrive by 5pm at the latest on the first day of retreat for mandatory orientation. *	I agree to arrive by 5pm on the first day of retreat and understand I will be turned away if I arrive after 5pm.
I have read and agreed to the terms of the Southern Dharma Cancellation Policy. *	Link to cancelation policy is accessible at the bottom of the registration form page. Please note that clicking this link may take you away from this registration form and delete your progress on this form.

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6 Payment

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