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Seven-day Bendoho Zen Retreats
Application Form
I would like to apply for the following retreatplease select

Personal details

Student status
Student numberfor current students only
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Nameyour full name
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Gender
Date of birthdd/mm/yyyy
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Addressyour full address
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Home phone number
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Mobile phone number
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Arrival and departure

Arrival daypick one!
Arrival time
access_time
Departure daypick one!
Departure time
access_time
I can offer someone a lift
I will be taking the airport shuttle bus and need transport from Creswick to Adekatepick one!

Retreat attendance

Samu (work practice) is an integral part of the retreat and participants are assigned to a Ryo (work group).

Previous attendance
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Previous Ryo and Roles
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Ryo preference for this retreatpick one!
Are you trained in First Aid?pick one!
Do you have your own oryoki set?pick one!

Health

Are you a snorer
List any food allergiesIf none, please write n/a
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Do you have any medical conditions that may affect your participation
List any medical conditionswhich may affect your participation
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Emergency contact details

**local only
Emergency contact #1name
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phone number
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Emergency contact #2name
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phone number
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Declaration
Please checkpick one!
My deposit fee of $65 will be paid the following way

Jikishoan Zen Buddhist Community

PO Box 475 Yarraville Victoria 3013 AUSTRALIA

Phone: 03 8307 0600 | email: contact@jikishoan.org.au

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