Daruma-ki Five-day Retreat 2017

Please Register by filling out this form by Monday, October 9ht, 2017. E-mail us here if any trouble with registering online. Thank you!

Full Name *

Gender

M

F

Contact Number

Email Address *

Address

Are you attending Daruma-ki ceremony on Sunday, October 22nd?

Yes, I will attend Daruma-ki ceremony and stay for lunch

No, I will leave before Daruma-ki ceremony

Total number attending Lunch including yourself (Required)

Suggested Donation (required) * $300 Five-day Sesshin (pay by Paypal) $325 Sesshin & Ceremony (pay by Paypal) $25 Ceremony & Lunch Make Donation by Check on the day of Service and/or Sesshin Make Donation by Cash on the day of Service and/or Sesshin

Participation Information & Room Assigment (required)

I need airport pick-up ($20)

I need housing

I snore loudly

I commute from home

I participate part-time

For housing, please indicate expected date & time of your arrival & departure.

For part-timer, please indicate expected time & day you'll be participating

Previous Experience for FIRST-TIMER

I have sat Sesshin before

I am currently studying with a Dharma Teacher

I am new to Sesshin and need an instruction

If clicked, briefly describe your previous experiences including practice centers:

Rinzai-ji Mailing List

Yes, please add me to the mailing list.

No, please do not add me to the mailing list

Medical/Emergency Information for FIRST-TIMER (Required)

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

Do you have an dietary restrictions and/or allergies?

Yes

No

If you clicked yes above, please specifically indicate the conditions

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Checkboxes

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