PBC-TN
REGISTRATION FORM
2007 FALL RETREAT

NOTE TO THOSE WISHING TO TAKE REFUGE VOWS:

Those wishing to take refuge, please contact:

Kirby Shelstad
kirbyshelstad@mindspring.com

615-385-4438

as soon as possible.


Please print and complete this form and bring it to retreat. We also ask that you email Debbie Thomas at dltariki@comcast.net to inform her of your intentions in order that we may better plan for your attendance.

If you are paying through PayPal, please do so by midnight Wednesday, October 12.

If you are paying with a check, please print and complete this form and bring it with your check to the registration table at the retreat.

Members receive a 10% discount at all PBC retreats nationwide. If you desire to become a member before the retreat, see below.

Suggested Donation
_____NonMembers: $65
_____PBC Supporting Members: $
50

_____
College students & children under 18: $25

Please make checks payable to PBC.

Your donation is 100% tax deductible and greatly appreciated.

Name(s): ____________________________________________________________

_____________________________________________________________________

Address:_____________________________________________________________

City: ___________________________________ State:_____ Zip: _____________

Phone:
__________________________ Cell Phone_________________________

Email:
___________________________________________________________

Do you wish to take refuge? ______________________

In case of emergency, please notify (name and phone number):

____________________________________Tel_______________________

I am a supporting PBC member according to the national policy.

HOLD HARMLESS AGREEMENT
Participation in any PBC activities and/or use of any PBC facilities, including but not limited to Padma Gochen Ling, involves a risk of accidental injury despite all safety precautions. I/We, assume all risks and release from responsibility and agree to indemnify and hold harmless the Padmasambhava Buddhist Center, Padma Gochen Ling, their officers, directors, volunteers and members, for any illness or injury to the individual(s) listed above, occurring during use of any facilities or participation in any activities conducted by the Padmasambhava Buddhist Center of Tennessee.

Signature(s): ______________________________________________  
  ______________________________________________ Date:_______________

 

PBC SUPPORTING MEMBERSHIP
Please note that the 10% member discount applies only to those who are currently committed to monthly or yearly memberships at any of the Padmasambhava Buddhist centers. Memberships are a vital component of the functioning of our centers. Suggested membership is $25/month or $40 per family.

If you wish to become a member, click here. We encourage all to join us as members and suport the Buddha, Dharma, and our Rinpoches.

Back to www.pbc-tn.org