RETREAT APPLICATION FORM

个人禅修申请表格

I wish to apply for: Meditation Retreat (October 20-November 5, 2017)	16 nights: $900 total/$300 deposit

1. PERSONAL DETAILS 个人资料

FULL NAME 姓名	RELIGION 宗教
GENDER 性别	MALE / FEMALE 男 ／女	CURRENT AGE 年龄
NATIONALITY 国籍	OCCUPATION 职业
MARITAL STATUS 婚姻状况	DATE OF BIRTH 出生日期
HOME ADDRESS	TELEPHONE 电话	OFFICE : 办公室
住家地址	HOME : 住家
CELL : 手机
EMAIL ADDRESS 电邮址
NAME & ADDRESS OF BUDDHIST ORGANISATION ASSOCIATED WITH 参与之佛教团体及地址（如有）

2. MEDITATION INFORMATION 禅修资料

PLEASE STATE TYPE OF MEDITATION METHOD USED. 现在使用之禅修法门
FOR HOW LONG HAVE YOU USED THIS METHOD? 已使用此禅修法门多久？
WHO IS YOUR CURRENT MEDITATION TEACHER, IF ANY? 现在的禅修老师是谁？（如有）
DETAILS OF YOUR PAST MEDITATION RETREATS 过去之密集禅修经验	Teacher老师 Type法门 Duration时间 When何时 1. 2. 3. 4. 5.

3. MEDICAL HEALTH DETAILS 健康状况

PLEASE STATE MEDICAL CONDITIONS (IF ANY) FOR EXAMPLE, HIGH BLOOD PRESSURE, KIDNEY / HEART PROBLEMS, ASTHMA, DIABETICS, ETC. 有任何严重疾病吗（如高血压、肾病、心脏病、哮喘、糖尿病等）	， YES是 NO否
DO YOU SUFFER FROM DEPRESSION, ANXIETY OR ANY OTHER MENTAL ILLNESS 是否有忧郁症、焦虑或其他精神病状况？ IF YES, ARE YOU UNDER MEDICATION FOR SUCH ILLNESS? 若有，是否正在服药？	YES是 NO否 YES是 NO否

4. CONTACT PERSON IN CASE OF EMERGENCY 紧急联络人

NAME 姓名	MR 先生 MS 女士	HOUSE ADDRESS 住家地址
RELATIONSHIP 关系	EMAIL ADDRESS 电邮址
HOUSE TELEPHONE 住家电话	HANDPHONE 手机

I shall observe 8 precepts and practice noble silence during my stay in AVMC/Catskill Zendo.

在正勤乐住禅林禅修期间我将遵守八关斎戒和圣默然的规约。

I shall strictly abide to the rules and regulations of AVMC/Catskill Zendo.

我已经阅读及了解禅修期间之规则，並将遵守此规则。

I shall not hold AVMC/Catskill Zendo responsible for my conduct that is contrary to its rules and regulations.

我同意正勤乐住禅林将无需为我不遵守规则的行为负责。

I shall not hold AVMC or Catskill Zendo liable for any mishap due to my own negligence during my stay

我同意正勤乐住禅林将无需为因我自身疏忽造成的意外负责。

PLEASE EMAIL THIS FORM TO : maureenbodenbach@yahoo.com. NOTE: Tick where appropriate, write “N/A” where not applicable, delete the irrelevant option. FOR ENQUIRIES: email maureenbodenbach@yahoo.com APPROVAL: You will be notified through email when your application is approved. DEPOSIT: Once you’ve been notified your application has been approved, please send a check for your deposit to: Maureen Bodenbach (please make check payable to this name) 41730 Onaway Dr. Northville, MI 48167 Deposits are due upon approval of your application. The balance will be due AUGUST 15, 2017.