Neftaly 5-Day Meditation & Relaxation Camp Registration Form Template.

Program: Neftaly Development 5-Day Meditation & Relaxation Camp
Module Code: SCDR.4.8.4
Purpose: To gather participant information, including prior meditation experience, individual goals, and preferred participation format (online or in-person). This form will help us tailor the meditation experience and ensure the camp meets each participant’s needs.

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Personal Information

1. Full Name:
   • First Name: ____________________________
   • Last Name: _____________________________
2. Email Address:
   • Email: ________________________________
3. Phone Number (Optional):
   • Phone Number: _________________________
4. Gender (Optional):
   • Female
   • Male
   • Non-Binary/Other: _______________
   • Prefer not to say
5. Age Group:
   • Under 18
   • 18-24
   • 25-34
   • 35-44
   • 45-54
   • 55-64
   • 65+

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Prior Meditation Experience

6. Have you practiced meditation before?
   • Yes
   • No
7. If yes, how long have you been practicing meditation?
   • Less than 1 month
   • 1-3 months
   • 3-6 months
   • 6-12 months
   • 1-2 years
   • More than 2 years
8. What type of meditation have you practiced? (Check all that apply)
   • Mindfulness Meditation
   • Breathwork / Breathing Exercises
   • Guided Meditation
   • Body Scan Meditation
   • Loving-kindness Meditation (Metta)
   • Transcendental Meditation (TM)
   • Yoga / Movement-Based Meditation
   • Other (Please specify): _____________________________
9. How would you describe your current meditation practice?
   • Beginner (I have just started practicing meditation)
   • Intermediate (I have some experience but still learning)
   • Advanced (I practice regularly and feel confident in my skills)

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Camp Goals & Intentions

10. What are your primary goals for participating in this meditation camp? (Select up to three goals)
    • Reduce stress and anxiety
    • Improve focus and concentration
    • Cultivate mindfulness in daily life
    • Deepen meditation practice
    • Enhance emotional well-being
    • Develop self-awareness and inner peace
    • Learn new meditation techniques
    • Improve sleep quality
    • Other (Please specify): _____________________________
11. What challenges do you currently face in your meditation practice (if any)?
    • Difficulty focusing or staying present
    • Time constraints
    • Lack of guidance or structure
    • Physical discomfort during meditation
    • Difficulty with breathing techniques
    • I’m new to meditation, so I haven’t encountered challenges yet
    • Other (Please specify): _____________________________

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Preferred Participation Format

12. How would you prefer to participate in this meditation camp?
    • In-Person at Neftalopolis
    • Virtually (Online)
13. If you prefer in-person participation, please confirm that you are able to attend at the specified location (Neftalopolis).
    • Yes
    • No
14. For virtual participation, please confirm that you have access to a reliable internet connection and can participate in live-streamed sessions.
    • Yes
    • No
15. Do you have any special needs or requirements that we should be aware of to ensure you have a comfortable and positive experience at the camp?
    • Yes (Please specify): ______________________________
    • No

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Additional Information

16. How did you hear about the Neftaly 5-Day Meditation Camp?
    • Neftaly Website
    • Social Media (Facebook, Instagram, etc.)
    • Friend/Family
    • Email Newsletter
    • Other (Please specify): _____________________________
17. Would you like to receive updates and information about future meditation events and workshops from Neftaly?
    • Yes, please send me updates.
    • No, I prefer not to receive further information.

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Emergency Contact Information (For In-Person Participants Only)

18. Emergency Contact Name:
    • Name: ___________________________
19. Emergency Contact Phone Number:
    • Phone Number: ____________________

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Acknowledgments & Consent

20. I agree to the Terms and Conditions and the Privacy Policy of Neftaly.
    • Yes
    • No
21. I consent to the use of my feedback and testimonial for marketing purposes (optional).
    • Yes
    • No

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Submit Registration

By submitting this form, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that my participation in the camp is subject to Neftaly’s terms and conditions and may require further verification or communication.

[Submit Registration Button]

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Confirmation Message (Upon Submission)

Once the registration form is submitted, participants will receive a confirmation message indicating that their registration was successful. This message can include:

• A summary of their selected participation format (online or in-person).
• Information about the next steps (e.g., email confirmation, event reminders).
• Contact information for any questions or concerns.

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Form Design Notes

• The form should be user-friendly and mobile-responsive, ensuring that participants can easily fill it out on any device.
• Use conditional logic where needed, such as showing the emergency contact section only for in-person participants.
• Include a progress bar if the form is lengthy to provide a visual cue of how much is left to complete.
• Ensure that the submit button is easily visible and accessible once the form is filled out.

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✅ Conclusion

This Neftaly 5-Day Meditation & Relaxation Camp Registration Form captures key participant details such as meditation experience, personal goals, and preferred participation format. The form is designed to be both comprehensive and user-friendly, ensuring that Neftaly can effectively tailor the camp experience to meet each participant’s needs and expectations.