Coming Home To Love: A BIPOC Insight Retreat in Nature

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1 Welcome

3 Optional Items

4 Participant Info

Phone *
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Address *
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City *
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Zip/Postal *
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What is your gender pronoun? (optional)
Please specify gender pronoun here
Are you a person who identifies as BIPOC (Black, Indigenous or Person of Color)? *	This is a retreat for BIPOC-identified people. If you do not identify as a person of color, we are happy to help you find another VMRC retreat.
Please specify BIPOC identity here
Birth Date (optional)	Knowing this helps us with housing assignments.
Do you have any physical health or mobility issues we should be aware of? *	If yes, please describe in the space provided. Please enter "no" otherwise.
Do you need to use a CPAP machine? *	If yes, please be sure to see very important CPAP information on our website under the Planning your visit Medical page. FURTHER, those using CPAP machines that are powered by electricity will be assigned to either casita 3 or 4, where we have solar batteries available. You must register for a CASITA if you plan to use your plug-in CPAP. If you bring your own rechargeable batteries or solar power source to run your CPAP then you may choose any lodging type.
Medically Necessary Dietary Requests	Gluten Free Dairy Free Lactose free Soy Free Egg Free Nut Free Vegan Vegan (with Honey) Specific Food Allergy (please explain below) Other (please explain below) If you have an allergy, please use the question below to adequately describe the nature of the allergy (for example, is the allergy anaphylactic?).
Diet Notes	Please explain any medically necessary dietary requests.
You will receive a practice discussion questionnaire two weeks before arrival. In the meantime, it is important for us to understand what supports you. Do you have any personal or psychological situations/diagnoses that would potentially require additional support or impact your retreat? *	If yes, please briefly describe the situation or diagnoses and how it might affect your retreat. Due to the remoteness of our center, this information will allow us to support your well being as fully as possible. Please enter "No" otherwise.
If you are a medical professional and would be willing to assist in the event of a medical emergency in our remote location, kindly note that here. (optional)
Emergency Contact Name *	Please include their relationship to you, e.g. sibling, spouse, parent, friend.
Emergency Contact Phone *
Have you been to Vallecitos before?	Yes No
How did you hear about this retreat?
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Email newsletter	Please send me the email newsletter
Cancellation Policy *	I have read and understood the cancellation policy.CANCELLATION POLICY: 45+ days = full refund, less nonrefundable $150 fee; 45-22 days = 50% refund; 0-21 days = no refunds. Cancellation policy applies to all registered guests including scholarship recipients. For more detail visit our website here.
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1 Welcome

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