City:__________________________________________________  State_________________ Zip______________
Home Ph:_______________________________  Work Ph:_________________________________
Emer. Contact (Name & Phone)_______________________________________________________
Circle the sesshin for which you are applying.
Rates are
member(those up-to-date with their monthly donations) / non-member.
Please register at least one prior to the beginning of sesshin
Those registering after one week prior to sesshin should include the late registration fee (see below).
  Nov 12 through 14
Part-time attendance days & times:_____________________________________________________________________


The cost for part-time attendance is $40 per day for members (those up-to-date with their monthly donations to PZC); non-members pay $60 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 by one week 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, 50% refund up to first day of sesshin. Newcomer's orientation is at 6:00 p.m.. Sesshin begins at 7:30 p.m. Please idicate sesshin attending in check memo.

If you do not have your own oryoki (eating bowls) and need to rent them, 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