Chapin Mill Work Retreat Form

Work Retreat Date*
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 Donations
There’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 Information
Name*
First Last
Date of Birth (mm/dd/yyyy)
MM slash DD slash YYYY
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Is this is a new address:
- Yes
- No
Home Phone
Work Phone
Cell Phone
Email Address*
Emergency Contact
Please enter the name and contact information for anyone you would like us to get in touch with in the event of an emergency.
Work Skills
Skills 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 Information
Please 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 restrictions
List 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.
Is this your first time using a Chapin Mill soaking bath?*
- Yes
- No
Chapin Mill Soaking Bath Guidelines. Anyone who wishes to use a soaking bath is required to read and sign off on these guidelines:
- There are two soaking baths; each includes a changing room, shower, hot tub, and cold plunge. During sesshin two people may be assigned to use a bath together during a 20-minute time slot. The first person showers and rinses off thoroughly before getting into the bath, and the second person follows. After soaking in the hot tub, you may also use the cold plunge. If others are scheduled to use the bath immediately after your time slot, it’s okay if you’re still finishing up in the changing room, but the bath and shower should be free.
- The temperature of the hot tubs is approximately 105-108 degrees Fahrenheit (40.5 - 42.2 Celsius). If you have any health conditions that might be aggravated by using the bath, check with your physician before signing this form. We DO NOT recommend using it if you may be pregnant, or if you have a history of high blood pressure, heart disease, diabetes, or fainting. DO NOT use the hot tub if you have a history of seizures or any other condition that may cause loss of consciousness.
- Signs of imminent fainting may include sweating; tingling of the lips, fingers or toes; light-headedness; and/or nausea. Should you experience any of these, get out of the tub immediately, but safely. If possible, get into a kneeling position on the floor with your head down, resting on the floor, or sit with your head resting between your knees.
- Regardless of any health conditions, limit your time immersed in the hot tub to a MAXIMUM of 5 MINUTES.
In submitting my request for a soaking bath, I agree as follows:*
- I’ve read the statement above and agree:
Rides and rooms
If 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 APPLICATION
In 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:
Phone
This field is for validation purposes and should be left unchanged.

Chapin Mill Work Retreat Form

Chapin Mill Work Retreat Donations

Personal Information

Work Skills

Medical Information

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 NOTIFY THE HEAD OF ZENDO OF ANY MEDICAL OR OTHER CONDITIONS THAT ARISE AFTER SUBMITTING THIS APPLICATION