APPLICATION FOR SESSHIN

PRAIRIE ZEN CENTER - 515 S. Prospect, Champaign, IL 61820 - (217) 355-8835

Name:_______________________________________________________________Age:_________Gender:________

Address:________________________________________________________________________________________

City:______________________________________________State_____________Zip__________________________

Home Phone: ___________________________________ Work Phone: ______________________________________

E-mail__________________________________________________________________________________________

Emergency contact (name & phone)___________________________________________________________________

Circle the sesshin for which you are applying. Rates are member / non-member. Apply 3 weeks prior to sesshin.

July 8^th to 11^th $105 / $150
app & payment due 6/17/10

Sept 1^th to 6^th $175 / $250
app & payment due 8/11/10

Nov 11^th to 14^th^{$105 / $150

app & payment due 10/24/10}

Please consider an additional contribution to assist with the Center’s commitment in support of its teacher $___________

If you attending part-time please specify times and dates:____________________________________________________

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 three 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 (Circle what you have experience in, not what you want to do):

cooking - electrical - carpentry - gardening - word processing - sewing - flower arranging

Physical and other conditions limiting participation (use back side of form, if necessary.): _________________________

______________________________________________________________________________________________

Serious allergies:_________________________________________________________________________________

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.

__________________________________________	________________________________________	_______________
Signature	Printed Name	Date

Complete this form and send it to the address above with your check made out to the Prairie Zen Center .