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Your Info

First Name

Last Name

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This helps us with our double occupancy room assignment

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Secondary Phone

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Emergency Contact Name

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Have you participated in any other mind training activities (TM, Silva, TMI, 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?

Do you smoke?

Program Cancellation / Transfer Policy

Due to advanced planning requirements by program participants and TMI 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 TMI 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 14 days before the start of the program. If you transfer within 14 days of the program a fee of $100 will apply.

  4. If you cancel your program 30 days or more before the start of the program a $100 fee will apply. If you cancel between 29 - 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.

The Monroe Institute (TMI) reserves the right to cancel a program 30 days in advance of the program date if there is not sufficient enrollment or for other unforeseen circumstance. If TMI cancels 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 30 days before your program starts. TMI will not be responsible for costs incurred due to cancellations.

Guarantees

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 TMI to make predictions or guarantees.

TMI 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.

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

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

Integrity of the experience:

TMI’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 Hemi Sync and SAM. 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 Hemi Sync or SAM.

For the purposes of attending a TMI 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 TMI residential programs when other introductory information and logistics are covered with the group, trainers will bring up this policy, specifically mentioning:

Use of alcohol, marijuana and/or any other illicit substances is not permitted at any TMI 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 The Monroe Institute, and especially of the benefits, educational and otherwise, which I expect to derive, I hereby release and forever discharge The Monroe Institute (TMI) 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 TMI during the program, my use of their facilities, 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 TMI, 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 TMI, use for myself or others, or disclose or divulge to others, any such trade secrets, confidential information, or any other data or materials of TMI without prior permission. Any participant found to be taping, filming or in any such manner recording any part of their TMI program content may be subject to legal consequence.

I understand that the materials presented by The 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 TMI residential programs. Should the use of alcohol or other drugs become a disruption to the group, participants will be asked to leave the program. For full alcohol/illicit drug use policy, click here.

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.

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.