CodeSpaVRregistrationForm

Welcome to the CodeSpa VR Programming Retreat!

Please complete all of the items on this form (in one session, as your input will not be saved until you submit). Providing the demographic information will help us in evaluating the diversity of our programs. Providing your health information will allow us to best care for your needs. Your information will be kept confidential.

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Occupation *

Age *

Gender *

Racial/Ethnic/Cultural Identifications *

Spiritual/Religious Affiliations *

Sexual Orientation *

Income Level (Low, Middle, High) *

Are you temporarily or permanently physically disabled? If so, what is your condition: *

Are you mentally challenged? If so, what is your condition: *

How did you hear about this retreat? *

State specifically and practically, one goal in participating in this retreat: *

Select your First Choice of Accommodation [Remaining Balance] *

Select your Second Choice of Accommodation [Remaining Balance] *

If you are attending with someone and wish to be roommates, please list their name(s) here: *

What type of phone will you be using? *

Android iPhone

Please share your dietary restrictions so that we can provide options for your meals: *

Are there any other health conditions, surgeries or medications you have had that may affect your participation? *

Please list an emergency contact person, including their name, phone number, and relationship to you: *

Anything else you would like to share? *

Submit

Thank you!
We very much look forward to sharing this experience with you!