RISHI's 2024 Tending the Flame Retreat & Training Workshop Application

1. Name and Education History *This question is required.

First Name
Last Name
Preferred First Name
Advanced Degree
School
Year of Graduation
License #
State of Issue

2. Professional Specialty *This question is required.

3. Professional Institution or Affiliation *This question is required.

Institution/Affiliation
Title
Professional Role
Years in Position

Professional Position (if more than one held concurrently)

Institution
Title
Professional Role
Years in Position

4. Work Contact Information *This question is required.

Address
City, State, Zip
Country
Work Phone
Work Email

5. Home Contact Information

Address
City, State, Zip
Country
Home Phone
Cell Phone
Home Email

7. Please indicate whether you are attending the Retreat and Training Workshop both (includes Sunday morning educational theory and training required to facilitate Finding Meaning Groups) or only the Retreat Workshop (Fri-Sat only)? *This question is required.