Prairie Zen Center Sesshin Application
Name:______________________________________________________Age:______Gender:_____
Address:________________________________________________________________________
City:___________________________________________  State__________  Zip______________
Home Ph:_______________________________  Work Ph:_________________________________
Email___________________________________________________________________________
Emer. Contact (Name & Phone)_______________________________________________________
Circle the sesshin for which you are applying.  Rates are member / non-member.
Apply 2 weeks prior to sesshin. 
May  22nd to 27th
$175 / $250
July  12th to 14th - Spfld
$105 / $150
Aug  28th to Sept 2nd
$175 / $250
Part-time attendance days & times:_____________________________________________________

The cost for part-time attendance is $35 per day for dues paying members; non-members pay $50 per day. For those on limited income, a fee of $25 per day is available on request. The registration form with payment must be submitted two weeks prior to sesshin. Late registration requires an added $10 per day of attendance. A full refund is available for cancellation up to one week before sesshin. Newcomer's orientation is at 6:00 p.m.; check in no later then 7:00 p.m. Sesshin begins at 7:30 p.m.

If you need to rent oryoki (eating bowls) check here ____ and add $5 to you sesshin fee.
WORK SKILLS (Select what you have experience in, not what you want to do):
Cooking__    Electrical__   Carpentry__   Gardening__   Word Processing__   Flower Arranging__
Physical and other conditions limiting participation (use back side of form, if necessary):

 _______________________________________________________________________________
Serious Alergies:__________________________________________________________________

"I agree to maintain a daily sitting practice between the time of application and sesshin and to participate fully in the entire sesshin schedule. I understand that my physical, mental, and emotional well-being are my own responsibility. I understand that Zen practice is not a substitute for therapy. I am seeking medical care or therapy for existing conditions. I have notified doctors or therapists of my participation and have ascertained their availability for consultation, if necessary. I am capable of undertaking the rigors of sesshin at this time. I have revealed all pertinent information on this form. I also agree to sign a waiver releasing the Center, its directors, volunteers, and the owners of 515 S. Prospect from any liability resulting from my participation in sesshin."

Signiture:_____________________   Printed Name_________________________  Date:_________
Send form and payment to:  Prairie Zen Center - 515 S. Prospect - Champaign, IL  61820