2014 Abhidhamma Study Retreat
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中文姓名
Chinese Name
Name *
Address 地址
Home Phone Number 電話 (家) *
Cell Phone Number 手機
Email Address 電子信箱 *
Age 年齡
Highest Education 學歷
Gender 性別 *
Required
Occupation 職業
I can attend 我能参加
I can only attend from Day ___ to Day ___，我只能参加____日至____日
English
中文
Chinese
Other language
Please describe any health related problem? 您有沒有健康方面的問題？  
 Such as Diabetes, hypertension, epilepsy, ulcers, etc., or any infectious diseases: pneumonia, pulmonary tuberculosis, typhoid etc., or external injury, surgery, bone fractures, etc…如糖尿病、高血壓、癲癇症、腸胃炎…等， 或傳染性疾病：肝炎、肺結核、傷寒…等，或運動性傷害：開刀、骨折…等
Do you have, or have you ever suffered from anxiety, panic attacks, manic depression, mental illness, etc.？您現在或過去有沒有精神（心理）方面的問題？(請說明症狀、病史、治療情形)
Medicine or foods you are allergic to are: 您對任何藥物或食物過敏？
You snore？ 您是否會「打呼」
Please provide any other information to take into consideration：請提供其它需注意事項：
I will need transportation from Cold Spring Station to Chuang Yen Monastery. 我需要Cold Spring火車站到莊嚴寺的交通接送
Please take a Metro North Train from Grand Central at 3:18pm on 8/29/2014, will arrive at Cold Spring at 4:31pm. The pick up van will leave on time. 請8/29/204於紐約中央火車站搭乘3:18pm火車前往Cold Spring，4:31pm抵達，接泊車將準時出發。
 I need to purchase the English textbook 購買英文教材 (A Comprehensive Manual Of Abhidhamma, $20.00)  
 I need a copy of the Chinese textbook 我需要中文教材  (阿毗達摩概要精解)
數量有限，每位學員限請一本，已經有書的學員，請將機會讓給其他人。
State briefly why you have decided to join us this time and what do you intend achieve? 簡述參加動機及期許
Emergency Contact Full Name
緊急連絡人中文姓名
Emergency Contact Chinese Name
Emergency contact person phone number (Daytime)緊急連絡人電話 (白天)
Emergency contact person phone number (Evening) 緊急連絡人電話 (晚上)
Emergency contact person phone number (Cellular) 緊急連絡人電話 (手機)
Relationship with Emergency contact person 與緊急聯絡人的關係
Waiver of liability 參加者聲明 *
It is fully understood that BAUS and/or Chuang Yen Monastery cannot be sued if any personal illness and/or injury is suffered during the retreat or if any property is damaged, lost, or stolen while a participant is at the retreat. 我對以上表格回答屬實，且於活動期間，如有病痛、金錢、物質之損失、任何意外事件而受到傷害， 概由參加者自行負責，美國佛教會及莊嚴寺不負任何法律責任、賠償責任。
Required
Signature 參加者簽名 *
Date 日期 *
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