11/26/2014 5-Day Meditation Retreat
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Name
中文姓名
Chinese Name
Address 地址
中文
Chinese
English
Other language
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
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
Please shortly described your previous meditation experience？曾修學過何種禪法?
Have you practiced Four Immeasurable meditation before? 是否參加過四無量心的禪法？
If yes, please answer the following questions.  如果是，請繼續回答下一個問題。
Place and Instructor? 地點及 指導者
Have you practiced meditation with the guidance of Ven. Dhammadipa Sak? 您曾參加過法曜法師所指導的禪修嗎？
If yes, please answer the following question. 如果是，請繼續回答下一個問題。
How many times ? 有幾次?
How did you learn about this retreat? 如何得知此禪修活動？
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」
Do you currently have any physical or mental health problem? 您是否有身心健康上的問題?
 
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
I will take train from Metro North Grand Central 3:50 pm to Cold Spring 5:00 pm （We will provide transportation from Cold Spring train station to Chuang Yen Monastery 2:02pm） ***** Please assembly at the parking lot. The van will absolutely leave on time *****
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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