EmailMe Form - Vajrayogini Counting Retreat

Name *
Surname *
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone *
Email *
Lay or Ordained? *
Lay
Ordained
Gender? *
Male
Female
Arrival Date *
DD / MM / YYYY
Departure Date *
DD / MM / YYYY
Accommodation *
If not available will you accept a dormitory? *
Your teacher's name *
We require a teacher's reference before we can confirm a place.
Your teacher's email *
Please provide us with your teacher's contact details, thank you.
NKT Centre and / or branch which you attend *
Additional Information
HYT Empowerment *
Have you received the Highest Yoga Tantra Empowerment of Vajrayogini and Heruka?
Message
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