Guest Student Application

Your name_______________________________________
Address_________________________________________
_______________________________________________

Home phone_______________________
Work phone_______________________
Email ____________________________
Date of birth_______________________
Male/female (circle one)
Emergency contact (required)___________________________
Name relationship address_____________________________
__________________________________________________

Home phone___________________________
Work phone ___________________________
Physician name__________________________
Phone ________________________________
Medical insurance co.________________________
Subscriber # ______________________________
(and group #) ______________________________
Intended dates of stay________________________
Arrival Date:________________ Departure Date:_______________

Please answer the following on a separate sheet of paper and attach to this application. This information will remain confidential and we appreciate your willingness to share it.

1. What is your interest in meditation? What is your background and current practice?

2. Do you have any medical problems that might affect your meditation practice or work practice at Zen Center? Please describe.

3. Do you have any history of mental illness? Have you ever been hospitalized? Please explain briefly and include dates.

4. Are you currently taking any prescribed medications? If yes, please specify. Do you intend to continue to take your prescribed medication during your stay at Zen Center?

5. Have you ever undergone treatment for alcoholism or drug addiction? Please explain briefly and give dates of treatment.

6. Is there anything else we should know about?

Send completed form to the contact person at the address of the specific center you wish to apply to. To apply to more than one center please copy this form. Zen Center addresses are located on the "Contact Us" page.

Please note Zen Center cannot be responsible for the financial support of guest students at any time. Applicants are expected to have adequate funds and to have arranged their future travel and housing before arriving at Zen Center. To facilitate your transition into the Zen Center community, we request that you refrain from recreational drug use prior to and during your stay.

Signature_____________________
Date ________________________