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Dare On Empowerment- Because She Handles It with Strength & Grace (a working title) w/ Jodi Silverman & CJ Stasik

* These fields are required

1 Welcome

3 People in your group

Guest 1		First name* Last name* Email* Phone (daytime)* I identify my gender as:* Your answer will support gender-based shared room assignment. If you identify as trans, non-binary, neutral, or otherwise genderqueer and are sharing a room, please select a gender that you are most comfortable sharing a room with. Please contact us in advance of your arrival or call 1-800-822-4547 if you have any questions or concerns.
Guest 1		First name* Last name* Email* Phone (daytime)* I identify my gender as:* Your answer will support gender-based shared room assignment. If you identify as trans, non-binary, neutral, or otherwise genderqueer and are sharing a room, please select a gender that you are most comfortable sharing a room with. Please contact us in advance of your arrival or call 1-800-822-4547 if you have any questions or concerns.

5 Delaware Highlands Conservancy Donation

6 Tell us about yourself

Phone (daytime) *
Address line 1 *
Address line 2
City or region *
State or province *
Zip or postal code *
County *
Country *
I identify my gender as: *	Your answer will support gender-based shared room assignment. If you identify as trans, non-binary, neutral, or otherwise genderqueer and are sharing a room, please select a gender that you are most comfortable sharing a room with. Please contact us in advance of your arrival or call 1-800-822-4547 if you have any questions or concerns.
Personal Expression
Diet Needs *	Our nutritionally balanced vegetarian meals are freshly prepared by our kitchen staff and served with homemade whole-wheat bread and homemade gluten-free bread. We will work hard to meet your special dietary requests but cannot guarantee to accommodate every individual request. Please contact us in advance of your arrival or call 1-800-822-4547 if you have any questions or concerns.
How did you hear about us?
Cancellation policy *	I will abide by the cancellation policy.We offer a full refund to guests who cancel their reservation at least seven days before arrival unless you are informed your program has additional restrictions. If you cancel between 7 days and 1 day in advance, a nonrefundable credit to your HI Retreat Center account (less a $50 processing fee) will be held for one year from the date of issue. No credit or refund is available if you cancel on your arrival day, do not show up, or leave a program, event, or accommodation early. View additional guest information.
No lifeguard *	I acknowledge that there is no lifeguard on campus and all water activities are at my own risk.
Foraging and Collection of Natural Resources: *	I agreeI acknowledge that foraging, or the collection of plants, fruits, mushrooms, or any other natural resource, is strictly prohibited on the premises of the Himalayan Institute. I understand that this policy is in place to preserve the natural environment, protect wildlife habitats, and ensure the safety of all guests.
Vegetarian, Dry, and Smoke/Vape-Free Environment: *	I agreeI acknowledge that the Himalayan Institute is proud to be a vegetarian, dry campus in order to foster an environment that is conducive to learning, self-discovery and healing. This means that neither alcohol nor other mind-altering substances are served or permitted on our premises. Furthermore, we kindly request that smoking take place more than 300 feet from any building, vehicles, and other people with special attention to minimizing any lingering smells on clothing that may affect the indoor experience of others.
Anything else that you'd like to tell us?	Roommate request? Any severe dietary allergens? Any medical issues? Questions about this program or the registration process? Recommendations for a future program? Comments about how Himalayan Institute programs have impacted your life?
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7 Emergency contact

Emergency contact name *	First and last name of a person NOT TRAVELLING WITH YOU.
Emergency contact relationship *	What is your relationship to your emergency contact? For example, "Contact is my father".
Emergency contact daytime phone *
Emergency contact email *
Emergency contact address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *

8 Confirm your registration

Wisdom. Service. Community.
952 Bethany Tpke, Honesdale, PA 18431 USA
800 822 4547
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