Your Full Name (required)
Your Email (required)
Your Cell or Telephone Number
Your address (include city and state)
Emergency Contact Name (required)
Emergency Contact Phone (required)
How did you hear about this retreat?
Have you done retreats with Tallahassee Chan Center 2 days or longer before? YesNo [group yes_retreat] If Yes to above, what month and year? [/group]
[group first_timer]
Occupation Date of Birth
The purpose of collecting this information is for the retreat teacher to help guide your practice. Please include as much information as possible below:
Do you attend the meditation at TCC regularly? YesNo Have you read anything from Guo Gu, if so what? Have you taken a meditation class from Tallahassee Chan Center? YesNo What meditation method do you use? Counting breathFollowing breathSamatha and VipassanaSilent IlluminationHua-tou Other Method: Have you studied meditation elsewhere? YesNo [group yes_other_meditation] If yes to question above, where? and in what tradition? [/group] If you have studied with another meditation teacher(s), who have you studied with? Have you done retreat with that teacher(s)? YesNo How long have you studied with that teacher(s)? How many years have you been practicing meditation? Do you practice meditation regularly? DailyWeeklyIrregularlyNever Date of last retreat (3 days or longer, month & year only) Why do you want to come on this retreat? Please also include any additional comments about your practice below [/group]
You must complete this portion of the retreat application even if you have informed us of medical issues before please include the information again. We request the following information to help us determine whether or not participation in a retreat will aggravate a serious medical condition, endanger a participant's health, or disrupt the functioning of a retreat. The information provided will be kept strictly confidential to protect the applicant's privacy.
Please include: -Serious back or leg ailments -Dizziness, palpitation, or shortness of breath due to meditation -High or low blood pressure -Heart Problems -Major surgery or infections disease -If you have been treated for serious emotional or psychological symptoms
Please briefly state the nature of each problem and the current condition. If you have no medical conditions please type None. (required)
By clicking "Send Application", I testify that all the information I have provided Tallahassee Chan Center is correct and complete. I understand that if I withhold any necessary information, I may be excluded from future participation. If I am accepted, I agree to finish the entire event. I understand that if I leave the event without permission, my application to future events may not be accepted. You will need to sign a liability waiver prior to attending the retreat.
