Residential Training Application - Rochester Zen Center

Name

First Last

Period you're applying for

Date of Birth

MM

DD

YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Home Phone

Cell Phone

Present occupation

Marital status. Are you living with your spouse?

Children and ages. Are they living with you?

Person to notify in case of emergency

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

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 directors

Listed 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)

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 or been treated for an addiction? Have you been hospitalized for emotional problems? If so, describe for what reasons, when and for how long a period you were treated, and the outcome of your 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