schedule
 
Application

Program: MuGon End-of-Year Reflection Retreat

Dates: December 28, 2014 - December 30, 2014


This form must be completed and returned to confirm your space on this retreat.

Instructions:please complete this form by filling out all areas. You can use the "tab" key on your keyboard or point and click to move from one field to the next. When completed, click the "Submit Application" button at the bottom of the page. If you have questions, call Senshin at (213) 387-2351 Wed. - Fri. 9:30a.m. - 5p.m. Your application must be submitted no later than one week before the retreat starts.

Contact Information

Name:
Gender: M   F
Address:
City:
State/Province:
ZIP:
Daytime Phone:
Evening Phone:
Email:

(required for retreat planning messages)
Best way to contact you the week before the program:
 

 


Participant Information
ZCLA member?
Yes No     Category? 
Expected arrival:
   Date:    Time:
Expected departure:
   Date:    Time:
Bringing a car?
Yes No
   
Where do you work?
What is your profession?
Do you need a CEU approval (Nurses only)?
Yes No

 


Room Assignment Information (multi-day retreats)
Do you need housing?
Yes No
Can you walk up and down stairs?
Yes No
Do you snore loudly?
Yes No
Do you want to rent linens ($10)?
Yes No
Any other room needs:
ZCLA is in the middle of Los Angeles. If you are a light sleeper, remember to bring earplugs.

 


Previous Experience
Have you sat sesshin before?
Yes No
If yes, briefly describe your previous experiences including practice centers, name of sesshin leader, dates and number of days:
Please describe your current practice:
Are you currently studying with a Dharma Teacher?
Yes No
If yes, please detail:

 


Retreat Information
During sesshin we use Oryoki bowls for traditional Zen meals. If you don't have an Oryoki set you can purchase one in our bookstore or rent one for $15.00.
Do you need Oryoki instruction?
Yes No
Do you need to rent an Oryoki set ($15)?
If not, you can or will need to purchase an oryoki set at the ZCLA bookstore ($45-55).
Yes No
For Zazen, do you use a:

Do you have any other specific needs for practice in the Zendo?

 

Would you like to be trained in a service position(s)?
If so, please list:

Any other information important for us to know:

 


Medical/Emergency Information - Required for non-members
Emergency Contact Person
(Please list at least one contact with phone numbers where they can be reached during the retreat.)
Name: Day Phone:
Relationship: Eve Phone:
Other contacts:
Answers to the following questions are necessary to help determine whether or not participation in a sesshin will aggravate a serious physical condition, endanger a participant's health, or affect the smooth functioning of the sesshin. Therefore, it is extremely important that all information be complete, current, specific, and clearly stated.

Have you recently had symptoms of headache, dizziness, palpitation, or shortness of breath associated with practicing meditation? Yes No
If yes, please specify:

Are there any current physical, psychological, medical or other conditions that may affect your participation in sesshin? Yes No
If yes, please specify:

Do you have an dietary restrictions or need for special meals or extra supplements? Yes No
If yes, please specify:

Do you have any allergies? Yes No
If yes, please specify:

 


I agree to maintain a daily sitting practice from the time of this application through the sesshin. I will participate to the extent I have specified above. I understand that my physical, mental, and emotional well-being are my own reponsibility and understand that practice is not a substitute for therapy. I am receiving treatment for any medical or psychological condition(s) that I have, and I have revealed all pertinent information on this form. I am capable of undertaking the rigors of sesshin at this time. I will sign a waiver releasing ZCLA from accident and injury liability.       I agree      I disagree


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