Rohatsu O-Sesshin Registration 2017

Full Name *

Contact Number

Email Address *

Expected Arival Date & Time (If flying, indicate Airline & Flight #) *

Expected Departure Date & Time (If flying, indicate Airline & Flight #) *

Check the following (REQUIRED) *

RSVP | Sangha Meeting on Saturday, November 18 | 11:00 - 16:30

I will attend

I will not attend*

*O-Sesshin will resume at 17:30 with Dinner.

Sesshin Fee $450 (Please make a payment by November 5, 2017)

Make payment online or Mail checks to: Mt.Baldy Zen Center

Medical/Emergency Contact Information (REQUIRED)

Do you have an dietary restrictions and/or allergies?

Yes

No

Please clearly indicate your dietary restrictions, and what you're allergic to? (This is not about your dietary preference) *

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

Yes

No

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

Yes

No

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