Residential Training Application (ver. 2)

"*" indicates required fields

e.g., she/her, he/him, they/them
Room assignment
For shared rooms, which room assignment best suits your gender?
Date of Birth*
(e.g., single, married, partnered, divorced)
Briefly 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?*
Have you attended an Introductory Meditation Workshop at the Rochester Center?*
Have you participated in a training program at the Rochester Zen Center before?*
Are you now associated with any church, spiritual, or meditation group(s) other than the Zen Center?


Please 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.

Work History

Are you now legally eligible for employment in the U.S.?*
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.
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.

Legal History

For 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*
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.*
Have you ever been charged with a sexual offense, offense relating to children, or crime of violence?*
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?*
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?*
Have you ever been reprimanded, or asked to leave or end your involvement/work in any program or organization providing services to children?*
Have you ever been the subject of a complaint or disciplinary proceeding concerning any professional license or professional affiliation held by you?*
Do you now or have you ever sought out or intentionally viewed child pornography?*

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.
Have you ever had counseling or psychotherapy within the last five years?
Have you ever taken psychiatric medication either from a psychiatrist, primary care physician, or other health care provider?
Have you had problems with addictive behavior (this includes problems with drugs, alcohol, gambling, or food), whether treated or not?
Have you been hospitalized for emotional problems?

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.
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