Retreat Application - Jikishoan Zen Buddhist Community

Seven-day Bendoho Zen Retreats

Application Form

I would like to apply for the following retreatplease select

Personal details

Student status

I am an IBS studentI am a financial member of Jikishoan

Student numberfor current students only

Nameyour full name

Gender

FemaleMale

Date of birthdd/mm/yyyy

Addressyour full address

Emaila valid email

Home phone number

Mobile phone number

Arrival and departure

Arrival daypick one!

Arrival time

Departure daypick one!

Departure time

I can offer someone a lift

YesNo

I will be taking the airport shuttle bus and need transport from Creswick to Adekatepick one!

YesNo

Retreat attendance

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

Previous attendance

Previous Ryo and Roles

0 /

Ryo preference for this retreatpick one!

Ino Ryo (Zendo)Shika RyoShu Ryo (General/newcomers)Tenzo Ryo (kitchen)No preference

Are you trained in First Aid?pick one!

YesNo

Do you have your own oryoki set?pick one!

YesNo

Health

Are you a snorer

YesNo

List any food allergiesIf none, please write n/a

Do you have any medical conditions that may affect your participation

YesNo

List any medical conditionswhich may affect your participation

0 /

Emergency contact details

**local only

Emergency contact #1name

phone number

Emergency contact #2name

phone number

Declaration

Please checkpick one!

I am aware of the voluntary nature of my participation in the meditation retreat. I am of sound mind and body or have obtained prior written approval from my medical practitioner to participate fully.

My deposit fee of $65 will be paid the following way

I will pay by cash in person at either Brunswick or Footscray. I wish to pay by direct deposit. Please send me the bank transfer details. I will pay by cheque, made out to "Jikishoan Zen Buddhist Community", and will post to PO Box 475 Yarraville VIC 3013.I am a full year Course C student and I am not required to pay the admission fee.

Jikishoan Zen Buddhist Community

PO Box 475 Yarraville Victoria 3013 AUSTRALIA

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