Registration Discovering Buddhism - Refuge in the Three Jewels I would like to register* for Refuge in the Three Jewels, Discovering Buddhism module.*Please fill out one form for each person who wishes to attend this classWould you prefer a chair or a cushion for this class?*ChairCushionPersonal DetailsName* First Last Email* Phone*Address Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Materials Fee and Facility FeesPlease select either Printed Materials ($12) or Digital Materials ($5).Materials FeePrinted Materials ($12)Digital Materials ($5)The Reading Packet will be distributed to you in either a digital or printed format. For those who newly complete their first DB Module you will also receive a DB Completion Card upon completing the module. The Materials Fee also covers other administrative costs in organizing the materials and class. (Dharma Friend Monthly Contributors also need to pay the materials fee.)Are you a current DCI Dharma Friend Monthly Contributor?*YesNoFacility Fees for this class are free for Dharma Friend Monthly Contributors.Would you like more information about becoming a Dharma Friend Monthly Contributor?Yes, pleaseNo, not at this time.Facility Fee*Total $40: I would like to pay the facility fees for all four nights at once.Total $10: I would like to pay the first night's facility fee ($10) now. Subsequent facility fees I will pay in cash on the night.Total: $0: I will pay each facility fee in cash on the night. Not now.The facility fees are $10 per evening session.Would you like to make an additional donation? (optional)YesNot at this time.We try to keep the costs low to enable as many as possible to benefit from our programs. If you are able and happy to make an additional donation it is most appreciated. Donations are eligible for tax rebates. Thank you.Donation Amount Any amount is most welcome. Please enter the amount you would like to donate in the box above. Donations are eligible for tax rebates as we are a Registered Charitable Trust.Total Amount $ 0.00 How would you like to pay?*I would like to pay in cash at the first evening I attend.I would like to pay in advance by internet banking.I would like to pay in advance by POLi facilitated internet banking.I would like to pay in advance by credit card via secure PayPal.Please note that PayPal takes a percentage of each transaction so this is not our preferred method of payment. Here are our Bank Details: Name: Dorje Chang Institute Account Bank: ANZ Account Number: 06-0589-0167320-00 Please mark payment “DB” + "your name" What date will you pay by internet banking?*This will help us to confirm payment has been received.POLi Facilitated Internet Banking Payment When you have finished, press ‘Submit', which will take you to the secure POLi payment page. There you can select your bank, and then login securely to your bank to make payment. After successfully completing payment you and DCI will receive a POLi payment notification email.PayPal Payment with either a PayPal Account or a Credit CardWhen you press ‘Submit’ below you will be taken to PayPal to process your payment using either a PayPal account or a credit card. To use a credit card press the ‘Pay using your debit or credit card’ link at the bottom of the page.What is the name of the Paypal Account OR name on the credit card you will use to pay with?*This will help us to confirm we have received your payment.Please arrive early on the first night you attend to complete payment. Thank you.You selected that you would like to pay in cash on the first night you attend this class. If you can try to arrive at least 15 minutes early this will allow time for you to make payment and for the evening to start on time. Thank you!Mobile Phone PolicyIn order to create a conducive environment for study, reflection and meditation, we ask you to please NOT bring your mobile phones with you. Or if you must bring, them please turn them OFF or at least put them on flight mode during the evening. Thank you.CommentsPlease provide us with any additional information which may help us. Feel free to include any practical questions you may have. Join Our Mailing List If you are already on our mailing list or wish to be added, please leave the box ticked.After you hit the submit button below, please check the following page for a confirmation message (or an error message – if more entries need filling in). Thank you.If the form is complete you will see a confirmation message thanking you for registering. This is followed by an automatic email that includes the details of your registration. This means we have received your registration. IF you receive an error message, please fill in the missing information and hit submit again. Please check.