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Program Name

Program Date

Your Info

First Name

Last Name


Date of Birth

Address Line 1

Address Line 2




Postal Code

Primary Phone

Secondary Phone



Emergency Contact Name

Emergency Contact Phone

Have you participated in any other mind training activities? (TM, Silva, Monroe, etc.)

Have you listened to any Hemi-Sync® or SAM audio exercises?

If you have experienced any difficulties, please describe.

What specifically about this program motivates you to attend, and what benefits do you hope to receive?

Are you presently on prescription medication?

Do you have any chronic, major illnesses or physical limitations we should know about?

Within the last six months, have you taken (or has a health professional advised you to take) any prescription medications or drugs which: a) affect your mental processes or mood; or b) treat a "chemical imbalance"?

Have you undergone psychotherapy/analysis?

Please provide the dates of this treatmen. Name, address, and phone of therapistm. For what reason(s):

Have you ever been hospitalized for mental breakdown or illness?

Please include details (date, diagnosis and medications):

Do you have epilepsy?

Have you ever had seizures?


In order that we may make your stay as comfortable as possible please answer the following questions.

How is your biological sex? (for assigning a roommate)

This helps us with our double occupancy room assignment

Your height?

Any issues with mobility?

Mobility issue details?

Any dietary restrictions?

Dietary restriction details?

Do you snore? (i.e. cPap)

Are you attending with anyone that you would like to share a room with?

What is the name of the person you want to share a room with?

Do you smoke?

Program Cancellation / Transfer Policy

Due to advanced planning requirements by program participants and Monroe staff, it is necessary that we administer the following policy:

  1. Registrations may be cancelled within one business day from the time of phone or online registration with no penalty. Please call the Monroe registrar at 434-361-1500 for assistance.

  2. If for any reason you are not accepted into a program, any payments you have submitted will be refunded in full.

  3. If you choose to transfer to another program you may do so one time, with no fee, as long as the transfer is complete more than 35 days before the start of the program. If you transfer within 35 days of the program a fee of $100 will apply.

  4. If you cancel your program 35 days or more before the start of the program a $100 fee will apply. If you cancel between 34 and 10 days, we will issue a non-refundable credit voucher (less $100 change fee) that can be used towards another program of equal value, within one year of the issue date.

  5. If you cancel less than 10 days before a program starts, if you leave a program early for any reason, or if you do not show up, no refund or credit voucher will be Issued. In emergency circumstances, please contact our Program Registrar at 434-361-1500.

Monroe Institute reserves the right to cancel a program 32 days in advance of the program date if there is not sufficient enrollment or for other unforeseen circumstances. If we cancel your program, you will be notified and given the option to transfer payment to another program or to receive a full refund.

NOTE: We recommend that you do NOT book a flight until 32 days before your program starts. Monroe will not be responsible for costs incurred due to cancellations.


In the past, many participants have entered our programs with the expectation that they would achieve an out-of-body state. While our programs do aid many individuals towards this goal, we must stress strongly that we offer no guarantees that the sessions and the continued exercises at home will result in an out-of-body experience. The variation between individuals is too significant for Monroe to make predictions or guarantees.

Monroe programs are not therapeutic in design, intent, or methodology and are not a substitute for medical treatment, psychotherapy, or any health program. We retain the right to determine if a participant may or may not continue with our sessions and program. If we deem an individual unsuited for continuation in a session or in the entire program, we will return the balance of his/her fee on a pro-rated basis.

Monroe Policy on Participant Use of Alcohol, Marijuana or other Illicit Drugs during Programs

It has consistently been Monroe’s policy to strongly discourage the use of alcohol and illegal drugs by participants during Monroe programs. The issue with use of mind-altering substance during a program goes to the heart of Monroe’s integrity.

Integrity of the experience:

Monroe’s goal is to teach participants the tools to experience, explore and control various states of consciousness. Participants who use drugs or alcohol can never be sure if their experience was the result of the exercise or a substance. They cheat themselves of knowing that the skill they learned was valuable and replicable.

Integrity of the group:

Use of alcohol and/or drugs has a negative effect on group energy and group dynamic. Behaviors often change when one is under the influence. Other participants may notice this behavior change, smell alcohol/marijuana, etc., and it breaks the understanding of trust agreed to by the entire group at the beginning of each program. Users often withdraw from the group in order to use and condone each other’s discouraged activity. This impacts group cohesion and support.

Integrity of support:

Our trainers are qualified to help participants understand and navigate their experiences with Monroe Sound Science. This would not be the case should alcohol, THC, etc., be involved. Our intent for the programs is that the source of the experience be the person with support from Monroe Sound Science.

For the purposes of attending a Monroe program, we request that any participant who normally uses cannabis for alleviating pain, use an alternative non mind-altering pain reliever during the program.

Reminder: During the first evening of all Monroe residential programs when other introductory information and logistics are covered with the group, trainers will bring up this policy, specifically mentioning:

Alcohol, marijuana and/or illicit substances and weapons of any kind are not permitted at any Monroe residential programs.  Should the use of alcohol or other drugs become a disruption to the group, participants will be asked to leave the program.

Terms & Conditions

In consideration of the mutual benefits which are expected to arise out of the activities which I intend to engage in under the sponsorship of Monroe Institute, and especially of the benefits, educational and otherwise, which I expect to derive, I hereby release and forever discharge the Monroe Institute and all officers, directors, employees, agents, representatives and/or volunteers and the successors of either from all claims and demands whatsoever which I, my heirs, executors, administrators and assigns have, or may have, against them by reason of any physical injury and mental and emotional issues of any nature whatsoever which I might suffer during or after my participation in the Program, my participation in any research conducted by Monroe during the program, my use of their facilities, Yoga instruction, Lake Miranon and/or the swimming pool, and I hereby expressly declare that any such activities are entered into by me voluntarily in an effort to increase my knowledge of the subjects under investigation.

I understand that, during the course of my program, there may be disclosed to me certain trade secrets of Monroe, including methods, processes, formulae, compositions, inventions, machines, computer programs and information regarding research projects and/or the results thereof. I shall not, during or at any time after the termination of my affiliation with Monroe, use for myself or others, or disclose or divulge to others, any such trade secrets, confidential information, or any other data or materials of Monroe without prior permission. Any participant found to be taping, filming or in any such manner recording any part of their Monroe program content may be subject to legal consequence.

I understand that the materials presented by Monroe Institute in this program are intended solely for use by program participants. I will not use the materials for any purpose other than my own personal use and agree not to copy, resell, reproduce and sell, modify and sell, or repackage and sell the materials.

I represent that I have not registered in the Program to handle a physical, mental or emotional problem. Further, I know of no recurring symptoms, physical or mental, which suggest to me that I may not be able to handle the types of activities described to me as part of the Program.

Use of alcohol, marijuana and/or any other illicit substances is not permitted at any Monroe residential programs. Should the use of alcohol or other drugs become a disruption to the group, participants will be asked to leave the program.

Weapons are not permitted onsite for any in person program - weapons would include but are not limited to guns and knives.

I agree to the above terms and conditions and certify that the answers given by me on this application are true and complete to the best of my knowledge. I also agree to advise the Monroe Institute registrar, if between the time I send in this form and the time my program begins, I experience any alteration in health or my mental condition that would affect my answers on this application.

Program Content Use Restrictions

The content of Monroe Institute’s residential and online programs, including lectures, written materials, audio/video exercises and all underlying audio support (e.g., sound frequencies) is owned by the Monroe Institute and may be subject to copyright and other intellectual property protections. The program content is intended only for use by registered program attendees, and only during their participation in the program. Program content, including fellow participants and trainers, in any format, may not be recorded, copied, distributed or used in any other manner outside its intended use, without express written consent of the Monroe Institute.

COVID Waiver

  1. I agree that I am personally responsible for my safety and actions while attending a Monroe Institute residential course (hereinafter, “Monroe”). I hereby agree to comply with all Monroe policies and rules, including but not limited to all Monroe policies, guidelines, signage, and written and verbal instructions.

  2. I acknowledge and understand that COVID-19 is a contagious disease, spread from person to person. I recognize and agree that Monroe is open to use by other individuals, and I understand that therefore I may be exposed to increased risk of contracting COVID-19.

  3. With full awareness and appreciation of the risks involved, I, for myself and on behalf of my family, spouse, heirs, estate, executors, administrators, assigns, and personal representatives, hereby forever release, waive, discharge, and covenant not to sue the Monroe, its board members, officers, agents, employees, volunteers, independent contractors, affiliates, successors, and assigns (collectively the “Released Parties”) from any and all liability, claims, demands, actions and causes of action whatsoever, directly or indirectly arising out of or related to any loss, negligence of the Released Parties, any third-party using Monroe, or otherwise, while participating in any activity while in, on or around Monroe, and while using any Monroe facilities, equipment or materials (whether they are sponsored by Monroe or a third party).

  4. I hereby agree to indemnify, defend and hold harmless the Released Parties from and against all costs, expenses, damages, claims, lawsuits judgements, losses, and/or liabilities (including attorney fees) arising either directly or indirectly from or related to any and all claims made by or against any of the Released Parties due to bodily injury, death, loss of use, monetary loss, or any other physical or non-physical injury from or related to my use of Monroe facilities, equipment, or materials, whether caused by negligence of the Released Parties or otherwise specifically related to COVID-19.

  5. By signing either electronically or in-person below, I acknowledge and represent that I have read the foregoing Waiver of Liability, understand it and sign it voluntarily as my own free act and deed, including without limitation the Release of Liability and Indemnification requirements contained in this document; I am sufficiently informed about the risks involved in being at Monroe to decide whether to sign this document; no oral representations, statements, or inducements apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this document for full, adequate, and complete consideration fully intending to be bound by the same. I agree that this Waiver of Liability shall be governed by and construed in accordance with Virginia law, and that if any of the provisions hereof are found to be unenforceable, the remainder shall be enforced as fully as possible and the unenforceable provision(s) shall be deemed modified to the limited extent required to permit enforcement of this waiver of Liability as a whole.

The Monroe Institute requires that you certify your application by submitting an electronic signature. If you are under 18 years of age, your parent or legal guardian must provide an electronic signature below:

Applicant’s Electronic Signature

Parent or Legal Guardian Electronic Signature

Please confirm all required fields are have a value.