Activist Wellbeing Retreat Registration Survey Please complete this survey to register for the Activist Wellbeing Retreat, 17-19 March 2017. If you have any queries get in touch with Jolene Elberth: 0400 675 310 jolene.elberth@gmail.com Question Title * 1. Please let us know your contact info. Name: City/Town: State/Province: Email Address: Phone Number: Question Title * 2. Why would you like to attend this retreat and what do you hope to get out of it? Question Title * 3. Can you say a little about your connection to activism? This could be paid or voluntary work, campaign involvement, current or past etc. Question Title * 4. Please note that this retreat is only open to those who can attend the whole time - 5pm Friday 17 to 3pm Sunday 19 March. Participation within the program is your choice (for example, sleeping in is fine!) but we need people to be on site from open to close. Can you attend for the whole time? Yes No Question Title * 5. AccommodationWe'll be staying in shared rooms (2-5 people per room) with shared bathrooms. You are also welcome to bring a tent. Solo accommodation may be available if you have a particular need. Bedding is not provided so BYO or hire some. I'm fine to share a room I need a private room (subject to availability and may involve extra cost) I'll bring a tent to camp I'd like to hire bedding ($30 for sheets, doona, rug, pillow, towel) If you have a preference about who you share with let us know. Question Title * 6. Food. All food provided is vegetarian, please let us know any additional dietary needs. Vegan Gluten free Dairy free Fructose intolerant Please let us know if you have any other dietary needs. If the kitchen is unable to cater for your needs you may bring your own food items that do not require cooking. Question Title * 7. Transport. We'll be connecting people to share rides from Melbourne to the venue. I can offer a lift to and from the venue I would like to get a lift to and from the venue I am travelling from interstate (please speak to us about timing before you book your flights) I'll find my own way there If you're up for carpooling please let us know where you'll be travelling to and from (whether or offering or seeking a lift). Question Title * 8. FeesFees are on a sliding scale of $200-$500 per person for the full retreat. Please think carefully about your means and relative privilege when deciding what to pay. $200 is a subsidised rate which covers basic food and accommodation but none of the other costs of putting the event on; $350 also contributes to facilitator and organiser fees and their accommodation and transport; $500 helps us cover all of our costs and makes subsidised places for others possible. We will issue an invoice for your fee or be in touch to discuss options. I will pay the following fee (include amount in the box below) I'd like to apply for a Pay the Rent space (free attendance for Aboriginal and Torres Strait Islander activists) Money is a barrier to me attending - please contact me to discuss options I'd like to donate to support attendance by low income activists (include amount in the box below) Fee and donation details Question Title * 9. Is there anything else you would like to add, or ask the facilitator or organiser? Please include any accessibility issues we should be aware of. Thanks! Click 'Done' and we'll be in touch to confirm your registration soon.If you have any queries get in touch with Jolene Elberth: 0400 675 310 jolene.elberth@gmail.comIf you want to warm up to the topic of activist health and wellbeing in the lead up to the retreat visit http://plantothrive.net.au/ Done
