Name:_____________________________________________________________Age:________Gender:________
Address:_____________________________________________________________________________________
City:__________________________________________________  State_________________ Zip______________
Home Ph:_______________________________  Work Ph:_________________________________
Email________________________________________________________________________________________
Emer. Contact (Name & Phone)____________________________________________________________________

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).
Jan 8 through 13, 2025
(Wednesday Evening to Monday Afternoon)
If attending part time, specify days/times. Also specify if Zoom attendance or at PZC and if eating and/or sleeping at PZC

________________________________________________________________________________________________

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Full COVID vaccination is required for attendance at PZC. Masks are optional.

Suggested donation for attendance at PZC is $40 per day ($30/day without meals). Zoom attendance is $25 per day. A reduced donation amount is available for those on limited income. 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.

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):__________________________

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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