2020 Silent Retreat: Journey Within

Completing this registration form on this secure web site sets you on your path to participate in Silent Retreat: Journey Within, a 5-day silent mindfulness meditation retreat led by Surja Tjahaja at Alton L Collins Retreat Center (April 5 – 10, 2020).

Please fill in the information below (* means that particular item is required). A confirmation email will be sent to you upon completion of this form.

Who is filling out this form?
First Name
Last Name
Email
Who are the participants?
*First Name *Last Name *Phone *Email
*Lodging Choice

Choose double or single occupancy. The fee covers five nights' lodging, 15 meals, and all program costs.  

Double room ($690)
Single room ($845)
Roommate Request

If you have a roommate preference, please list that person's name here.

If you have not given a roommate request, we will assign you a roommate.  We prefer to assign roommates to persons who identify as the same or similar genders.  Please indicate your preferences below.  

Gender Identity
Preferred gender identity of roommate
*Do you have any specific dietary needs? (if yes, see below)
Yes
No
What are your specific dietary needs?

We strive to meet all dietary needs of our guests as part of our ministry of hospitality. Our food is cooked from scratch, using whole food ingredients featuring whole grains and plenty of fresh fruits and vegetables. We serve family style--there is no buffet line or cafeteria option. We are happy to accommodate your specific needs, but we need you to let us know in advance how we can best serve you.

Allergies or Sensitivities (please explain below)
Pescatarian (eats fish, eggs, and dairy)
Vegetarian (eats eggs and dairy but no fish)
Vegan
Gluten-Free
Dairy-Free (please explain below)
No refined sugar
Other needs

Please note that we do not have emergency treatment for life-threatening allergies on site.

You may contact our office (503-637-6411) to discuss emergency medical treatment possibilities. 

*Is this an airborne allergy?
Yes
No
*Description of allergies or sensitivities
Tree nuts (please specify below)
Eggs
Dairy (please specify below)
Wheat
Peanut
Soy
Corn
Gluten
Preservatives
Shellfish
Nightshades
Acids
Other (please specify below)
*Do you eat honey?
Yes
No
*Do you eat butter?
Yes
No
*Do you eat sheep or goat dairy?
Yes
No
Please describe further if needed

If appropriate, please give us more detail about how to meet your dietary needs.

Other Considerations?

Indicate below if there is anything else we need to know in order to prepare for your arrival--for instance, you are bringing a nursing infant, or you use a wheelchair, or you need to bring medical equipment with you. It is easier for us to accommodate your needs if we know in advance. Thank you!

Financial Assistance

A limited amount of financial assistance is available for this retreat. If you would like to be considered, please submit a letter regarding your need to Surja at surja@gmail.com.

Yes
No
No answer
Optional Donation to Alton L. Collins Retreat Center

If you would like to make a donation to the Collins Retreat Center, please enter the amount of your donation. Any amount is acceptable--thank you for your generous support!

$
Only number values are allowed
*I understand that my registration form is not complete unless I see a confirmation screen and receive a confirmation email.

If you have difficulty completing your registration form, please contact our registrar at office@collinstreatcenter.org or call the Collins office at 503-637-6411. If you do not receive a confirmation, you are not registered for this event.

Yes
No
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