Residential Training Application (ver. 2) "*" indicates required fields 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 PhoneWhat 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 directorsReferencesPlease include complete address, city, state, zip code. One reference must be a person of a different gender, one a family member (if unavailable, please describe your situation), and the rest non-family members.Name* First Last Relationship* 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 Name* First Last Relationship* 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 Name* First Last Relationship* 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 Work HistoryPresent occupation* Are you now legally eligible for employment in the U.S.?* Yes No Employment History*Please provide the company name, address, and phone number of your employer. Include what position you held, the name of your supervisor, your job duties, and your reason for leaving.Employment History*Please provide the company name, address, and phone number of your employer. Include what position you held, the name of your supervisor, your job duties, and your reason for leaving.Listed below are typical work activities at the Center. Fill out any with which you've had experience.Carpentry Gardening Painting Licensed electrical work Heavy labor Kitchen work Office Plumbing Sewing Legal HistoryFor any “yes” answers, please attach a detailed explanation in writing. An affirmative answer does not necessarily disqualify an applicant from employment.Have you ever been the subject of a civil lawsuit involving sexual misconduct, sexual harassment, sexual abuse or other immoral behavior or conduct, involving adults or children? Have you ever been the subject of an investigation or allegation of sexual misconduct, sexual abuse or sexual harassment involving adults or children* 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.Have you ever been convicted of a criminal offense (felony or misdemeanor) involving moral turpitude or violence (Crimes of moral turpitude involve fraud, theft or dishonesty.) Answer “yes” if you have entered a plea agreement, including a deferred sentence or deferred judgement arrangement in connection with a criminal case. Answering “yes” does not necessarily preclude applicant from employment.* Yes No Have you ever been charged with a sexual offense, offense relating to children, or crime of violence?* Yes No Do you have any disciplinary action or investigation pending by an employer, or other organization, professional association, or licensing body, for violence, sexual misconduct, or misconduct involving children?* Yes No Have you ever been disciplined or dismissed from any volunteer or employment position for any reason or following an allegation of sexual misconduct, physical aggression, verbal aggression, or other inappropriate behavior or conduct?* Yes No Have you ever been reprimanded, or asked to leave or end your involvement/work in any program or organization providing services to children?* Yes No Have you ever been the subject of a complaint or disciplinary proceeding concerning any professional license or professional affiliation held by you?* Yes No Do you now or have you ever sought out or intentionally viewed child pornography?* Yes No 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.I hereby authorize you to contact any references or organizations listed in this application and authorize such references or organizations to release any information contained in their files or records concerning me. In consideration of the receipt and evaluation of this application by the Rochester Zen Center, I release the Rochester Zen Center, all of its agents, and all such references and organizations from any and all liability for any damage that may result from furnishing such information to you. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application, except what may be required by law. I understand that an appropriate criminal background check will be conducted. I authorize investigations of all statements contained in this application. I specifically authorize the Rochester Zen Center to undertake a criminal background check of my past. I understand that I must be interviewed and screened before I begin training or employment at the Rochester Zen Center. I understand that I can withdraw from the application process at any time. I understand that the Rochester Zen Center has a policy of ZERO TOLERANCE FOR ABUSE and takes all allegations of abuse seriously. I further understand that the Rochester Zen Center cooperates fully with the authorities to investigate all cases of alleged abuse. Abuse of any kind is grounds for immediate dismissal from training or employment and possible criminal charges. I am not a pedophile or child molester. I have not perpetuated physical abuse, sexual abuse, emotional abuse or neglect against a child, a student or disabled adult, and I have never been accused of these acts. I understand and agree that if I am offered a conditional training opportunity or employment with the Rochester Zen Center, my appointment is for no definite period and may, regardless of the date or method of payment of my wages or salary, be terminated by either party at any time without previous notice or cause and is subject to change in wages, conditions, benefits and operating policies. I agree that if the Rochester Zen Center accepts me for training, in the future a potential employer may contact the Rochester Zen Center or its representatives concerning my work record and my work performance. I hereby consent to and authorize persons employed by the Rochester Zen Center to divulge any and all information they consider relevant to any person representing him or herself to be an employer or potential employer of mine with respect to my work and/or performance of my job at the Rochester Zen Center. This consent specifically includes any information related to any allegation or investigation of child abuse or sexual abuse or molestation in any form. I understand and agree that in the performance of my duties as a trainee or employee of the Rochester Zen Center, or after I leave the Zen Center, that I must hold in confidence any and all confidential information that I come in contact with regarding my employer or its business. I understand and agree that it is critical to the mission of the Rochester Zen Center that all trainees and employees conform to the highest standards of safety, interpersonal conduct, and morality. I affirm that I will strictly comply with the Rochester Zen Center’s policies and procedures, including those concerning child safety and protection, sexual abuse and misconduct, and interpersonal relationships. I understand and agree that failure by me to abide by such policies and procedures may result in my immediate dismissal. My responses above are true and correct. I understand and agree that any false answers or statements made by me on this application or any supplement thereto, or any false statements made to the representative(s) of the Rochester Zen Center during the interview process will be sufficient grounds for not extending an offer of training or employment, or immediately discharging me, no matter when discovered.I HAVE CAREFULLY READ, UNDERSTAND AND AGREE TO THE FOREGOING “APPLICANT STATEMENT” AND FURTHER UNDERSTAND AND AGREE THAT A COPY OF THIS APPLICATION SHALL BE AS VALID AS THE ORIGINAL.* I agree Date* MM slash DD slash YYYY Δ