Name First Last What name do you go by? What gender pronouns do you use? e.g., she/her, he/him, they/themRoom assignment Women's Men's All-gender For shared rooms, which room assignment best suits your gender?Period you're applying for Date of Birth Month Day Year Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Home PhoneCell PhonePresent occupation What is your relationship status? (e.g., single, married, partnered, divorced)Children and ages. Are they living with you?Person to notify in case of emergency AccommodationsBriefly describe any accommodations you would like to request (e.g., full-time use of a chair for meditation, use of hearing assistance technology). Please note: If you have a food allergy, you should also communicate this information directly to the Head Cook.Are you a member of the Rochester Zen Center or any of its affiliates? Yes No If so, which one and for how long? Have you attended an Introductory Meditation Workshop at the Rochester Center? Yes No If so, when? Have you participated in a training program at the Rochester Zen Center before? Yes No How long have you been doing zazen regularly? How long do you sit each day? Are you now associated with any church, spiritual, or meditation group(s) other than the Zen Center? Yes No If yes, list the groups and names of their teachers or directorsListed below are typical work activities at the Center. Fill out any with which you've had experience.Carpentry Gardening Painting Electrical work Heavy labor Kitchen work Office Plumbing Sewing Have you ever been convicted of a crime?* Yes No If you answered yes, give the following information for each conviction: year, place, and court of the conviction; the crime of which you were convicted; the sentence you received. Also, please describe the circumstances surrounding the crime and conviction.Medical Information (please answer in detail)The following medical questions will help us understand any difficulties that may arise in your training and meditation practice. This information will be kept confidential. Please notify the Head of Zendo if any of your answers change later.Do you have any chronic medical problems, major or minor such as diabetes, heart disease, hernia, allergies, dizziness or fainting, ulcers or any other similar condition?Do you have any serious physical problems connected with sitting zazen? Include stiff legs, sore back, or any other problem.Have you ever had counseling or psychotherapy within the last five years? Yes No Have you ever taken psychiatric medication either from a psychiatrist, primary care physician, or other health care provider? Yes No Have you had problems with addictive behavior (this includes problems with drugs, alcohol, gambling, or food), whether treated or not? Yes No Have you been hospitalized for emotional problems? Yes No If you answered yes to any of the four preceding questions, please describe, including length and outcome of any treatment.Have you had any major operations? If so, when and what were they?Are any of the above conditions aggravated under stress?As far as you know, do you have any other mental conditions or tendencies (such as an addiction) or physical problems (such as bad back or knees) which could interfere with or influence your participation in training.Please send separately a statement detailing why you wish to participate in training at the Center. Also send a current photograph if we don't yet have one. Either email and jpeg or snail mail are OK. Standard training fees, payable on arrival, are $100 (for the first training program you take part in) as well as $15 (non-members $25) for the first 21 days only. If the fees are a financial hardship, please call the Center, and we will try to accommodate you.If accepted for training, I agree to abide by all the guidelines for conduct of a trainee.* I agree Δ
