Application – Zen Center of Los Angeles

Participant Contact Information

First Name *

Last Name *

Email *

Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Sesshin Information

Will you attend via Zoom or in-person? *

on Zoom
in-person at ZCLA

Participation type? *

Full time
Part time

ZCLA Member? *

Yes
No

If no, would you like to attend a sitting period prior to attending sesshin?

Yes
No

Select the retreat you are applying for:

Expected Arrival Time *

Date

Time

Expected Departure Time *

Date

Time

Bringing a car? *

Yes
No

Room Assignment Information

Your housing assignment will be made using the information on this form. It is important that you clearly state any accommodations you may require in the "additional notes" section.

Do you need housing? *

Yes
No

Gender:

Male
Female
Nonbinary
Prefer Not to Disclose

Okay with a Roommate:

Yes
No

We will do our best to accommodate requests for single rooms, but may have to assign roommates depending on the number of participants.

Please type any additional notes regarding your room needs:

Do you have mobility issues that make walking up and down stairs difficult? Do you snore loudly?

Previous Practice Experience

REQUIRED FOR NEWCOMERS

Have you sat sesshin before?

Yes
No

If yes, briefly describe your previous experiences including practice centers, name or sesshin leader, dates and number of days:

Please describe your current practice:

Are you currently studying with a Dharma Teacher?

Yes
No

If yes, please detail:

Emergency Contact Information

Please list at least one contact with phone numbers where they can be reached during the retreat.

Emergency Contact Name *

First

Last

Relationship

Day Phone *

Evening Phone *

Email *

Emergency Contact Name

First

Last

Relationship

Day Phone

Evening Phone

Email

Medical Information

Answers to the following questions are necessary to help determine whether or not participation in a sesshin will aggravate a serious physical condition, endanger a participant's health, or affect the smooth functioning of the sesshin. Therefore, it is extremely important that all information be complete, current, specific and clearly stated.

Have you recently had symptoms of headache, dizziness, palpitation, or shortness of breath associated with practicing meditation? *

Yes
No

If yes, please specify:

Are there any current physical, psychological, medical or other conditions that may affect your participation in sesshin? *

Yes
No

If yes, please specify:

Do you have any dietary restrictions? *

Yes
No

If yes, please specify:

Do you have any allergies? *

Yes
No

If yes, please specify:

PLEASE NOTIFY PROGRAM STEWARD, MYOKI, OF ANY MEDICAL OR OTHER CONDITIONS THAT ARISE AFTER SUBMITTING THIS APPLICATION

I agree to maintain a daily sitting practice from the time of this application through the sesshin. I will participate to the extent I have specified above. I understand that my physical, mental, and emotional well-being are my own responsibility and understand that practice is not a substitute for therapy. I am receiving treatment for any medical or psychological condition(s) that I have, and I have revealed all pertinent information on this form. I am capable of undertaking the rigors of sesshin at this time. I agree that neither the Zen Center of Los Angeles nor any of its employees, officers, trustees, or trainees - nor any person acting as sesshin monitor or otherwise supervising, overseeing, or conducting any aspect of 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 sesshin, whether or not such loss or injury is caused by any act or omission of the Center or any of the persons specified above.

I've read the statement above and agree: *

I Agree
I Disagree

Zen Center of Los Angeles

Program Application