Live Extended Education Program Registration

Congratulations on your acceptance to the LEEP program!

To secure your space in the program, please complete the following registration form and submit your non-refundable $1,450.00 deposit payment.

* These fields are required

1 Welcome

2 Live Extended Education Program Price

3 Complete Your Information

Please provide your complete contact and personal information.

Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Alternate Phone	Please use format 831 555 5555 to enter your phone number
Birth Date *
Gender *
Age Range *
Emergency Contact Information *	Please enter the full name and phone number.
Diet Request *	Please select your preferred meal option. All foods containing gluten or common allergens are labelled accordingly. We are unable to accommodate special dietary requests.
Serious Food Allergy?	Please leave blank if answer is none. This field is for serious food allergies only. All food items containing reported allergens will be labelled accordingly. If you have serious food allergies, please bring suitable items that are non-perishable.
Dietary Restrictions	Gluten Free No Soy No Garlic No Onions Select 1 or more dietary restrictions if applicable.
Senior Citizen?	over 65 yearsEsalen provides a discount for Senior Citizens over 65 years, please also select the Senior Discount item under Optional Items to receive your discount.
Former Student at Esalen? *	Are you a former Residential Student (work scholar)?
Are you bringing a vehicle?
Is this your first time to Esalen? *	Yes No
How did you hear about us?
Stay Connected	Esalen's monthly newsletterPlease add me to Esalen's monthly newsletter for the most current updates on workshop offerings and other news from Big Sur.
COVID-19 Guidelines *	I have fully reviewed and accept the updated COVID-19 GuidelinesView Esalen COVID-19 Guidelines
LEEP Cancellation Policy *	I accept the cancellation policyIf you choose to cancel, the $800.00 deposit is non-refundable. Additional cancellation fees apply. ● If you change or cancel your reservation more than 14 days before your arrival date, you will forfeit 15% of the remaining $800.00 ($120.00) in addition to the non-refundable deposit. Any remaining amount paid will be refunded. ● If you change or cancel your reservation more than 7 but less than 14 days before your arrival date, you will forfeit 30% of the remaining $800.00 ($240.00) in addition to the non-refundable deposit. Any remaining amount paid will be refunded. ● If you change or cancel less than 7 days before your arrival date, no refund will be provided. ● Exceptions to the cancellation policy may be made on a case-by-case basis for COVID exposure or COVID-related travel restrictions.

Continue

4 Inclusion and Equity Survey

Please select which race and/or ethnicity you identify with *	Indigenous, Native American Black or African American Asian American, Desi-American, Pacific Islander Hispanic or Latino Multiracial, biracial Asian Middle Eastern White Other Prefer not to answer
Other (Fill in)
Income range	$31,000 or less $31,000 - $42, 000 $42, 000- $126,000 $126, 000 - $188, 000 $188,000 or more Prefer not to answer
Education	High School diploma Associates degree BA MA PhD MD JD N/A Prefer not to answer
Thank you !	We appreciate your time and support in completing this survey.

5 Payment

To reserve your space we require a non-refundable deposit of $870.00.

The full payment of the reservation’s balance is due ten days prior to arrival and will be automatically charged to your credit card.

Sub Total	$0

Taxes	$0

50% Deposit	$0

Pay	Choose to pay a deposit or the full amount right now.

Due Now	$0 $0

First Name
Last Name
Card Type
Card Number *
Card Expiration *	Month Year
Card Security Code	usually a 3 digit code on back of card

Continue

Live Extended Education Program Registration

1 Welcome

2 Live Extended Education Program Price

Select an option*

Residential Student Housing

3 Complete Your Information

4 Inclusion and Equity Survey

5 Payment