Samadhiraja King of Meditation Registration Samadhiraja 2022 Registration "*" indicates required fields Retreat Option* Full Retreat - September 16-September 20 Weekend retreat - September 16- September 18 Accomodation Option* On Site Dorm On Site Camping Off-Site Full Retreat -Sliding Scale for Dorm RoomBase $450.00Sustaining $660.00Benfactor $880108 Pillar discount $405Full Retreat - Sliding Scale for Camping or OffsiteBase - $360.00Sustaining - $528.00Benefactor - $704.00108 Pillars Members $324.00Weekend Retreat - Sliding Scale for Camping or OffsiteBase - $200.00Sustaining - $264.00Benefactor - $352.00108 PillarsPersonal DetailsFirst Name* Last Name* Date of Birth MM slash DD slash YYYY Email Address* Phone Number* Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCity* Address Are you subscribed as a 108 Pillars Member?* Yes No Are you applying for a work study position? Yes No Emergency Contact PersonName* Phone Number* Retreat DetailsPrior Nine Yanas Retreats with Kyabgon Phakchok RinpochePlease select only if you require a chair to sit Yes Covid 19 Vaccine Received? Yes No Other If other, please explain: Medical Issues, including food and other allergiesDietary Preferences Vegetarian Vegan Gluten Free Dairy Free None Comments and questionsWould you like to subscribe to the Gomde Cooperstown Newsletter? Yes please! Δ Next
