UCLA Teen Mindfulness Retreat

UCLA Mindful Awareness Research Center
, 310-206-7503

APPLICATION FORM

UCLA Teen Mindfulness Retreat

Ojai, California

June 16-21, 2012

Retreat cost: The price is determined by a sliding scaled based on family income with a suggested payment of 1% of gross annual household income (for example, $600 is the expected price for a family with income of $60,000), with a maximum expected payment of $2000. This price structure recognizes that some families can afford to pay more than others and that there is value for all teens in having a diverse retreat. Our intention is that no qualified teen will be turned away for lack of funds. We also welcome additional contributions to help make this retreat widely accessible to teens independent of funds. Please contact us for further information about any part of this policy.

We leave the 1% calculation up to the teen’s family.

Please specify the total amount you will be paying: ______

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Your application will be reviewed by the retreat teachers. If accepted into the retreat, we then will contact you about making the payment. Funds will be returned if cancellation is made before 3 weeks prior to the retreat (minus a $25 cancellation fee). No refunds after this date.

For further information about the retreat, please contact .

Confidentiality: We take protecting your privacy very seriously. We will not disclose information about you to anyone who is not directly involved without your written permission, or as required by law. All of the following information will be kept confidential.

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Please write or type the following clearly

Teen name ______Date of birth______

Address ______Gender ______

City, State, Zip ______

Teen Email ______Best Phone ______

Parent Name ______Parent email ______

Cell Phone ______Day Phone ______Night Phone ______

EMERGENCY CONTACT DURING RETREAT

Name ______Relationship ______

Day Phone ______Night Phone ______

Does your family have medical insurance? Yes / No

If yes, what is the company name and policy number that we may use in case of an emergency?

______

CARPOOLING

Do you need a ride TO or FROM the retreat? ____ No ____ Yes [ ] TO [ ] FROM

Can you or your family offer a ride TO the retreat to someone from your area? ____ No ____ Yes

Can you or your family offer a ride FROM the retreat to someone from your area? ____ No ____ Yes

If yes to either question, may they call you directly? Yes / No

MEDITATION EXPERIENCE

Please describe your experience with meditation (we realize you may not have any experience and that is not required):

______

YOUR INTERESTS GENERALLY?

Please write about some of your main interests.

______

WHY ARE YOU INTERESTED IN THIS RETREAT?

Please describe why you are interested in attending this retreat? (Even though meditation experience is not required, it is important that you want to be there and we want to know why.)

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ACCOMODATIONS

Do you snore? Yes / No ______Do you have insomnia or other sleep disorder? Yes / No ______

Do you have any special medical needs? If so, please describe here: ______

Please give any other information that will assist the retreat manager in making room assignments:

______

Please indicate any special dietary requirements you want us to know about?

______

Do you have allergies to food or medications? If so please list them.

______

If you were to have an allergic reaction, please specify what medications should be taken, and when (eg what symptoms would be displayed and what medication should be administered).

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CELEBRATING DIVERSITY

At the Mindful Awareness Research Center, we celebrate all kinds of diversity. Offering the following information is optional and will be kept strictly confidential by the retreat staff. It will help us create an environment supportive to all teens who come to the retreat. We realize these categories are limited, yet it will be helpful to us to know if you belong to any of the following:

___ indigenous peoples___ people with low income

___ people of color___ people with disabilities

___ lesbian, gay, bisexual, transgendered people___ other (please describe below)

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MENTAL AND PHYSICAL HEALTH

Do you have any history of physical illness or limitations which might be aggravated by or interfere with sitting or walking meditation? Yes / No

If yes, please describe here: ______

Are you currently seeing a therapist or counselor? Yes / No

Therapist’s name: ______

Have you ever been diagnosed with a mental illness? Yes / No If yes, please describe the diagnosis, treatment and dates: ______

Have you ever attempted to take your life? Yes / No If yes, please state when: ______

Are you currently taking any prescription medications? Yes / No

If yes, please list each medication and the condition it is being used to treat: ______

Please describe any present circumstances that might be placing you under additional stress or make meditation difficult for you (e.g. loss of a loved one, leaving home, divorce, etc.): ______

Are you in recovery from addiction to drugs or alcohol? If yes, for how many months/years? ______

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Do you currently smoke? Yes /No ______If yes, would quitting for the retreat be possible? Yes /No ______

Note: We deeply care that people overcome addiction to nicotine as soon as possible and strongly suggest that you stop smoking for this retreat (although this is not required). We will offer you support if you want to quit. If you smoke, you need to bring enough cigarettes with you before you arrive; you will not have an opportunity to buy or ask for cigarettes once the retreat has started. Smoking at the retreat site is limited to designated areas.

We have a zero-tolerance policy for the use of illegal drugs and alcohol during this retreat by anyone, including staff and teens. This means anyone found using illegal drugs or alcohol will be asked to leave the retreat immediately. Do you understand this policy?

Yes I understand this policy and agree not to use any illegal drugs or alcohol on the retreat. ______

Have you answered all the questions above honestly and not left out important information? Yes / No______

Your signature ______Date ______

*FINANCIAL ASSISTANCE

The sliding scale fees offer a reasonable cost of the Teen Retreat while recognizing that some families can afford to pay more than others. We recognize that in some cases even paying the minimum is not possible.

Scholarship: If you cannot afford the lower end of the sliding scale as determined by annual household income, please describe your financial situation so we can begin to assess your needs: ______

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