March 2019 Retreat Application
Thursday, March 21, 7:00pm - Sunday, March 24, 12:00pm (3 days)
Registration & payment deadline: 5:00pm, Monday, March 11, 2019

Note the new process for application and payment:
1. Submit the completed application, along with your payment either via PayPal or by check (your payment reserves a spot for you in the retreat).
​2. You will be notified by email once your application has been reviewed and approved.

Refund Policy: Due to the advanced planning and preparation required to host sesshin/retreats, NZC's general policy is that if a registrant cancels after the registration deadline has passed, the fee is no longer refundable. If a registrant cancels before the registration deadline, the fee is refundable, less a $25 administrative fee and any additional fees incurred by NZC (i.e. PayPal fees). If your application is not approved for any reason, the fee will be returned to you in full, less any fees incurred by NZC (i.e. PayPal fees).

Email address *
First Name *
Your answer
Last Name *
Your answer
Phone *
Your answer
Physical address *
Your answer
Describe your intention for this retreat. Be specific - we're looking for something more personal and meaningful than "to sit." *
Your answer
Describe any significant physical or mental health issues: *
Your answer
Have you ever been hospitalized for a mental health issue? If yes, indicate when this occurred and briefly describe the circumstances. *
Your answer
Are you currently under the care of a psychotherapist or psychiatrist? If yes, briefly describe the circumstances. *
Your answer
Do you take medication for any physical or psychological condition? If so, briefly list medication and condition it addresses. *
Your answer
Do you have a history of chemical dependency? Note: sobriety is a requirement for participation in retreat. *
List any significant dietary restrictions or foods that cause allergic reactions. (Note: We are unable to accommodate individual dietary preferences. All meals are vegetarian. They may include dairy and/or eggs, which are served on the side when possible. ) *
Your answer
List an emergency contact person, their relationship to you, and phone #: *
Your answer
Do you have oryoki (Zen eating bowls): *
Would you prefer to *
If you plan to sleep at the center, how do you rate on the snoring scale:
No one has ever told me that I snored
Neighbors living several houses away have called 911, mistaking my snoring for an animal in distress
If you have not done sesshin (a residential retreat with nine or more hours of sitting meditation) with Dosho and Tetsugan, indicate how many days of sesshin you've completed during the last five years and where you did these sesshin. *
Your answer
In need of financial aid? Partial scholarships may be available. If you need assistance, please describe your circumstances, including the amount of the fee that you can contribute.
Your answer
Anything else you would like the teachers to know?
Your answer
In submitting this application, I agree as follows: I will participate in all scheduled retreat activities and complete the entire retreat or the portion of the retreat that I've committed to. I understand that to participate in retreat, or any activity at the Nebraska Zen Center, sobriety is required. WAIVER OF LIABILITY: I understand that retreat is a period of strenuous traditional Zen training. In accordance with this understanding and in consideration for Nebraska Zen Center accepting me into retreat, I agree that neither Nebraska Zen Center nor any of its employees, officers, board members, or trainees, nor any person acting as a retreat officer, shall be liable to me or to any other person for any loss or injury suffered by me in connection with my participation in retreat, whether or not such loss or injury is caused by any act or omission of Nebraska Zen Center or any of the persons specified above. I have read the above statement and agree: *
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