Chapin Mill Work Retreat Form Work Retreat Date*June 28 - July 2, 2022Enter the date of your last vaccination. (Please note that we are requiring full vaccination to attend in person events.)* MM slash DD slash YYYY Are you attending the entire retreat?* Yes No If not, briefly tell us which days and times you would like to attend:Chapin Mill Work Retreat DonationsThere’s no fee for the work retreat (although donations for food are welcome). If you would like to donate, after submitting this application you'll have an opportunity to make a tax deductible contribution to the Center via the PayPal Giving Fund.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.Work SkillsSkills I have to contribute to the work retreat (check all that apply): Kitchen Housekeeping Repairs & Maintenance List other work skills you think might be important Medical InformationPlease answer the questions below in detail, even if you’ve done so previously. 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 us 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 work or sitting, please describe the nature of the problem:Dietary restrictionsList any dietary restrictions or food allergies that might affect your time with us 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 the work retreat?Please complete the following two questions if this is your first time visiting 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 OF ZENDO OF ANY MEDICAL OR OTHER CONDITIONS THAT ARISE AFTER SUBMITTING THIS APPLICATIONIn submitting this application, I agree as follows:WAIVER, ASSUMPTION OF RISK AND RELEASE: In consideration for my being permitted by Rochester Zen Center (RZC) to participate in its Chapin Mill Work Retreat, I understand that RZC will provide to all Work Retreat participants full training in all operations which they are asked and agree to perform, including full safety instructions, and I will not perform any operation during the Work Retreat without having received all such relevant instructions. I will adhere to those instructions throughout the Work Retreat. I hereby assume all risk in connection with my participation in the Work Retreat. I hereby waive and release all claims against RZC and its officers, trustees, and representatives (the “Releasees”) with respect to their negligence and intentional wrongdoing in connection with the planning for and administration of the Work Retreat, and I agree not to pursue any claim or action against any of the Releasees with respect to the Work Retreat in litigation, arbitration or any other proceeding. I understand and acknowledge that RZC will permit me to participate in the Work Retreat in reliance upon my representations and agreement as set forth above.* I’ve read the statement above and agree: PhoneThis field is for validation purposes and should be left unchanged. Δ
