Name:_____________________________________________________________Age:________Gender:________
Address:_____________________________________________________________________________________
City:__________________________________________________  State_________________ Zip______________
Home Ph:_______________________________  Work Ph:_________________________________
Email___________________________________________________________________________
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 8 to 11
$120 / $200
Jan 16 to 21
$200 / $300
 
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