Sesshin Application Sesshin Date*September 24 to October 1, 2021November 6 to November 13, 2021January 8 to January 15, 2022Please choose a sesshinWill you attend via Zoom or in person? (Please note that we are requiring full vaccination for those who attend in person.)* In person On Zoom If you will attend in person, please enter the date of your full vaccination MM slash DD slash YYYY Are you attending the entire sesshin?* Yes No If not, tell us which days and times you would like to attend:Sesshin Fee:For IN-PERSON SESSHIN, our rate is $45/day for members. For non-members, it’s $65/day. For those coming part-time, the charge per block is $12/block for members and $15/block for non-members. However, for ONLINE SESSHIN, We leave it up to each participant to contribute whatever they can afford. This year the Center could very much use an infusion of revenue to help compensate for the cancellations of sesshin and rental retreats at Chapin Mill, but then many members will also feel financially strapped. So just give what you can afford. Part-timers and Zoom participants can sign up for all or any of the 4 main blocks of sitting:Block 1: 4:45am - 7:00amBlock 2: 9:30am - 12:30pmBlock 3: 1:30pm - 3:45pmBlock 4: 7:00pm - 9:30pmAbbot’s Fund:For members unable to afford the sesshin, Roshi has a fund he can use to provide assistance. If you would like to donate to this fund and help others to attend sesshin, please indicate the amount here:Please enter a number greater than or equal to 0.00.Personal InformationName* First Last Date of Birth (mm/dd/yyyy) MM slash DD slash YYYY Address Street Address City State / Province / Region 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 Is this is a new address: Yes No Home PhoneWork PhoneCell PhoneEmail Address* Emergency ContactPlease enter the name and contact information for anyone you would like us to get in touch with in the event of an emergency.Membership StatusCurrent Status:* Member Non-member Length of Membership (years)Please enter a number greater than or equal to 0.If, in a formal ceremony, you have become the student of a Zen teacher, please enter the teacher’s name: Sesshin ExperienceHave you attended a sesshin before* Yes No If yes, please list the most recent and longest sesshins you’ve attended:Month/YearLocationConducted byNumber of Days Medical InformationPlease answer the questions below in detail, even if you’ve done so for a previous sesshin. Please list any medical conditions you have that require regular care or medication (include pregnancy, current infections, high or low blood pressure, communicable diseases or chronic headaches).Medical Conditions and Medications (if any)Please list anything you would like Roshi and the monitors to be aware of.Please list any hospitalizations or major surgeries you have had in the past five years:Describe any significant problems with your back or legs:I need to sit in a chair: Never Part-Time Full-Time If you have experienced dizziness, fainting, palpitations or shortness of breath during sitting, please describe the nature of the problem:Dietary restrictionsList any dietary restrictions or food allergies that might affect your sesshin and give some indication of their seriousness. NOTE: if you have a serious food allergy, please also contact the Head Cook directly.Describe any other allergies (including allergies to drugs):Soaking bath or shower Shower Soaking bath The Chapin Mill Retreat Center has two communal soaking baths. If you would like to take a bath rather than a shower, check that box, and if we can schedule you for one, we will.Rides and roomsIf coming from out of town, will you need a ride from the airport, and would you like a room at Arnold Park or Chapin Mill before or after sesshin?Please complete the following two questions if this is your first sesshin with the Rochester Zen Center or if the information has changed since you last answered these questions:Please give details of any serious psychological problems or crises, whether or not you were treated or hospitalized:Have you ever attempted to take your own life? Yes No PLEASE NOTIFY THE HEAD MONITOR OF ANY MEDICAL OR OTHER CONDITIONS THAT ARISE AFTER SUBMITTING THIS APPLICATIONIf there are any pressing circumstances, such as difficulty arranging time off from work, that would prevent you from applying to another upcoming sesshin, please explain here. In submitting this application, I agree as follows:I will finish the entire sesshin or that portion I’ve applied for.WAIVER OF LIABILITY: I understand that sesshin is a period of strenuous traditional Zen training involving some 10 hours of formal meditation per day during which participants may frequently be struck with the kyosaku (encouragement stick). In accordance with this understanding and in consideration for the Center’s accepting me to sesshin, I agree that neither the Rochester Zen Center nor any of its employees, officers, trustees, or trainees - nor any person acting as sesshin monitor or otherwise supervising, overseeing, or conducting any aspect of sesshin - shall be liable to me or to any other person for any loss or injury suffered by me in connection with my participation in sesshin, whether or not such loss or injury is caused by any act or omission of the Center or any of the persons specified above.* I’ve read the statement above and agree: PhoneThis field is for validation purposes and should be left unchanged.