Zen Center of Los Angeles

Membership Application

Thank you for your interest in the Zen Center of Los Angeles!
Upon receiving your application someone from the Membership Circle will contact you to provide you with additional information about what it means to be a member of the Zen Center of Los Angeles.

Clilck here for fillable PDF copy

Personal Information

Name *

First

Last

Date of Birth *

Sex *

This information will be used for housing purposes during stay-over programs

Phone *

explain: When? Disclaimer

Email *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Marital Status

Name of Spouse or Partner, if applicable

Children (Names & Ages)

Membership Category

Please select: *

Click here for more in formation on membership levels and fees

Membership Start Date *

Method of Payment: *

Mail a check addressed to: Zen Center of Los Angeles, 923 S. Normandie Ave, Los Angeles, CA 90006 Cash may be left in clearly marked dana envelopes in the donation boxes onsite Credit card payments can be processed online or you can call the office during regular business hours, Wednesday-Friday 9a.m.-5 p.m., to leave a card on file.
For Venmo and Paypal, please visit our regular donation page

Education

Highest Grade Completed:

College/University Degree:

Languages (fluent):

Work Experience

List three most recent jobs, including your present work:

Job Title

Name of Business

Dates (approx.)

Job Title

Name of Business

Dates (approx.)

Job Title

Name of Business

Dates (approx.)

Do you do volunteer work?

If yes, where:

Are you interested in volunteering at the Zen Center? If so, what is your area of interest:

For more information on Shared Stewardship visit zcla.org.

Other areas of interest:

Practice Information

Do you have meditation experience?

If yes, for how long, what type of meditation and so you still do this practice?

Have you made a formal commitment to be a student of a Dharma teacher?

If yes, please give us the name and contact information of the teacher:

First

Last

Phone

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Have you received the precepts (Jukai or Tokudo)?

When?

Where?

Who was your preceptor?

Physical & Psychological Health

How would you rate your general physical health?

Good
Fair
Poor

Do you have any limiting health problems that you're aware of that we should know about?

If yes, please explain:

How would you rate your general psychological and emotional health?

Good
Fair
Poor

Have you ever been in psychotherapy?

If yes, when?

Have you ever been hospitalized for psychiatric treatment?

If yes, when and where?

In case of emergency while at the Zen Center, who should we contact? *

First

Last

Relationship

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Zen Center:

How did you hear about the Zen Center of Los Angeles?

Select all that you have attended:

Why are you interested in becoming a member of this Zen Center?

Disclaimer and Release

Participants in the training programs at Zen Center of Los Angeles may find some aspects of the programs physically or mentally demanding. The programs include physical work and certain other requirements. I understand that I may freely decline to participate in any work which in my sole judgment might be dangerous to my health. I also understand that I may speak with a teacher or senior practitioner at Zen Center to address any difficulties I might have. I understand that my physical, mental, and emotional well-being are my own responsibility and I further understand as a Member that Zen practice and ZCLA programs are not a substitute for therapy. I represent that I am receiving any treatment I consider appropriate, in consultation with medical or psychology professionals of my choice, for any medical or psychological condition(s) I have, and I have disclosed information in this regard on this form. Accordingly, I hereby release Zen Center of Los Angeles, its officers, directors, staff and teachers from any injury sustained by me as a Member in the course of participation in ZCLA programs. Further, I hereby indemnify, agree to defend and hold Zen Center of Los Angeles, its officers, directors, staff and teachers (collectively, “ZCLA”), harmless from and against any and all claims, actions and causes of action, injuries (including without limitation physical, financial, legal and reputational injuries), damages, costs, expenses and losses sustained by ZCLA arising from my conduct or my participation and any other ZCLA program in which I participate.