7-DAY SESSHIN APPLICATION FORM

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TURTLEBACK ZENDO, Inc. turtlebackzendo@gmail.com 609-213-6006

CONFIDENTIAL

Name ____________________________________________________________

Cell Phone ____________________ Home _________________ Email ________________________

Mailing Address________________________________________________________________________

Present Occupation__________________________________________ Birth Date_____/_____/_________ (mm/dd/yyyy)

Emergency Contact __________________________________

Relationship______________________

Emergency Phone(day)_____________________________ (night___________________________

PLEASE ANSWER ALL QUESTIONS IN DETAIL INCLUDING THOSE RELATED TO MEDICAL CONDITIONS YOU MAY ATTACH ADDITIONAL SHEET(S) OF PAPER IF MORE ROOM IS NEEDED
(PLEASE WRITE ALL ANSWERS IN YOUR OWN HAND)

  1. In the past 12 months, have you applied to a sesshin conducted by Mitra Bishop roshi for which you have not been accepted? If so, which?

  2. Which sesshin have you attended in the last 12 months? Please list by month, location, sesshin length and the name of the leader/teacher.

  3. If you have not attended a sesshin in the last 12 months, when, where, and under whom was the last sesshin you attended and how long was it?

  4. Have you ever attended a sesshin conducted by Mitra Bishop roshi? If so, how long was it?


    _______________________________________________________________________




MEDICAL INFORMATION

Please answer the following questions in detail and in your own hand, regardless of whether you have done so for previous sesshin. If necessary, attach an additional paper to complete your answers. The purpose of this medical information is to help determine whether attendance at sesshin will in any way aggravate a serious physical or mental condition, endanger an applicant’s health or affect the smooth functioning of the sesshin. For this reason it is extremely important that all information be current, specific, and clearly stated, in regard to both active and inactive conditions. This medical information is solely for use by the teacher and officers and will be kept confidential.

  1. Briefly describe any medical or psychiatric conditions you have that require care or medication.

  2. List any hospitalizations or major surgeries you have had in the past 5 years; also list any major organs missing.

  3. List any medications you are currently taking under a doctor’s prescription, and the reason for their use.

  4. Describe any problems you are having with your back or legs.

  5. Describe any other condition bearing on your physical or mental state, such as pregnancy, current infections, communicable diseases, or chronic headaches.

  6. Are you in psychotherapy at this time?

  7. Please list any serious dietary restrictions or food allergies. All food served at Turtleback Zendo during the sesshin is vegetarian.

  8. Describe other significant allergies.

  9. Have you ever attempted to take your life?

PLEASE NOTIFY THE TEACHER OR TURTLEBACK ZENDO (turtlebackzendo@gmail.com or 609-213-6006) OF ANY MEDICAL CONDITIONS THAT ARISES AFTER YOU SUBMIT THIS APPLICATION.

By SIGNING this application, I agree to the following:

  1. (1)  I will finish the entire sesshin or portion of the sesshin for which I have been accepted.
  2. (2)  WAIVER of LIABILITY: I understand that sesshin is a period of very intense traditional Zen training involving 10 (ten) or more hours of formal meditation per day. In accordance with this understanding and in consideration for Turtleback Zendo, Inc. accepting me to the sesshin, I agree that neither Turtleback Zendo, Inc. nor any of its employees, officers, directors, trustees, or trainees—nor any person acting as sesshin officer or otherwise teaching, supervising, overseeing, or conducting any aspect of the sesshin—shall be liable to me or to any other person for any loss or injury suffered by me in connection with my participation in the sesshin, whether or not such loss or injury is caused by any act of omission of Turtleback Zendo, Inc. or of any other persons specified above.

Signature of Participant ______________________________________________________ Date __________________________

Signature of Guardian _____________________________________________ 


APPLICANT NAME (PRINT) _____________________________________________________________________________

The total fee for the entire full time, 7-day sesshin is $490. One may attend a portion of the sesshin at a fee rate of $70 per day or $35 per half day. Dana for the teacher is optional but deeply appreciated. It is usually offered at the end of your participation in the sesshin.









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Please check or X the box of the day(s) and time(s) you expect to be present at the sesshin site. Full Day (Includes Overnight Room)

Full DayFriday
March 20		Saturday March 21Sunday March 22Monday March 23Tuesday March 24Wednesday March 25Thursday March 26Friday March 27Saturday March 28
Arrival No Fee|||||||Includes Breakfast
Half dayAM|||||||Includes Breakfast
PM|||||||

APPLICATIONS are DUE on or before March 2, 2020. In order for your application to be considered, a deposit of $70 ($35 if applying for half day of the sesshin) must be enclosed with the written application. Payment must be made by check or money order. If you are local you may also pay at the Zendo by arrangement with the Treasurer. Checks etc. should be made payable to Turtleback Zendo, Inc. with 2020 Sesshin in the memo. If the applicant is accepted, the deposit will be applied to the total amount owed for the sesshin. If not, the deposit will be returned to the applicant.

ACCEPTANCE: You will be notified by either Shotai (Serita Scott), President or other officer of Turtleback Zendo, Inc. on or before March 7, 2020 regarding the status of your application. We will use your cell phone number if you indicated one and will leave a voice mail if you don’t answer. If you have questions contact Turtleback Zendo as indicated below using our phone or email as desired.

BALANCE DUE: On acceptance, the balance of your fees must be paid by check or money order and postmarked within 2 (two) days of your acceptance but no later than 11:59pm of March 14, 2020. If you are local you may also pay at the Zendo by arrangement with the Treasurer. Checks etc. should be made payable to Turtleback Zendo, Inc.

A REFUND will be given ONLY if the cancellation request is received by Turtleback Zendo on or before 11:59pm of March 16, 2020. If the date is met, you will receive a full refund otherwise all fees are forfeited.

Payments and communications should be made to:

Turtleback Zendo, Inc.
4 Alyce Court
Lawrenceville, New Jersey 08648
turtlebackzendo@gmail.com

Phone: 609-213-6006. If you reach voicemail, please leave the date/time of your call, return phone number, and a brief message. You will receive a callback within 24 hours.

Please retain a copy of your application and allow 5-7 days for your application to arrive. Let us know that it is coming using our email address or our phone (609-213-6006).