Registration Form Name * First Name Last Name Email Address * Age * Phone * (###) ### #### City * Educational background * Occupation * Do you suffer from anxiety, depression, or other mental illness? * Please explain Are you currently under the care of a medical practitioner or psychiatrist? * Do you sleep well? * Briefly explain why you are interested in receiving comprehensive meditation instruction? * I can attend the classes on each of the four consecutive days * Please select Yes No Payment is due in full at or before the beginning of the course, via cash, check, Zelle, Venmo or credit card/paypal. A 3% service fee applies to credit card payments. Checks should be made payable to Jill Wener. Paypal and Venmo email: jill@jillwener.com. Zelle email jill@jillwener.com. No additional payment is required for attendees of meditation retreats. Electronic Signature * I understand and have filled out the form to the best of my ability First Name Last Name Today's Date * MM DD YYYY Thank you!
