Four Divine Abidings Samadhi Retreat 四無量心定禪八
Instructed by Abbot Ven. Dr. Dhammadipa || 指導老師 方丈和尚 法曜法師

Checking in 報到 at 2 pm on December 22nd, 2018
Concluding 放香 at 7 am on December 30th, 2018
Detailed Schedule: https://tinyurl.com/uszi-winter18

at US Zen Institute, 19225 Liberty Mill Road, Germantown MD

in English/Chinese bilingual format || 中英雙語

Registration ends on 11/30 || 報名於 11/30 截止

For any questions please contact || 如有任何問題,請聯絡:
Allen Tsaur (a.t.tsaur@gmail.com)

Personal Information 個人資料
Chinese Name 中文姓名
Your answer
English Name 英文姓名 *
Your answer
Gender 性別 *
Age 年齡
Your answer
Education Background 學歷
Your answer
Occupation 職業
Your answer
Contact Information 聯絡資料
Email Address 電子郵件 *
**Please double-check that this is filled out correctly, as you will be contacted primarily through email || 一切活動的消息將會透過電子郵件跟您聯絡,煩請檢查此欄是否填寫正確**
Your answer
Phone Number 聯絡電話 *
Your answer
Home Address 聯絡地址 *
Your answer
Attendance Information 活動參與資料
Attendance Dates 參與日期 *
Who recommended you to join this retreat? 請問你的介紹人是? *
**First-time participant must fill out this accurately, otherwise it may impact your chance of being accepted || 第一次參加禪修的學員務必正確填寫此欄,否則會影響錄取**
Your answer
Have you learned Divine Abidings samadhi meditation under Ven. Dhammadipa before? If yes, how many Divine Abidings retreats have you attended? 您是否有跟法曜法師學習過四無量心定禪修法門?如果有,請問曾經參加過幾次四無量心定禪修? *
Do you have any other prior experience in meditation? Please describe briefly. 您是否有任何其他的禪修經驗?煩請簡短敘述。
Your answer
Chinese Language Skill 中文程度 *
English Language Skill 英文程度 *
Request for Lodging 住宿安排
This is ONLY for participants who are not from the DC Metro Area. We will get in contact with you when you receive your request to stay at US Zen during this retreat. 目前僅提供外州學員在禪堂掛單,收到報名表後,我們隨後會再跟您聯繫確認
Health Related Information 健康方面信息
Do you have any medical conditions such but not limited to diabetes, hypertension, epilepsy, ulcers, etc., or any infectious diseases: pneumonia, pulmonary tuberculosis, typhoid etc., or external injury, surgery, bone fractures, etc… 你是否有健康方面的問題如糖尿病、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 *
Your answer
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) *
Your answer
Are you allergic to any medicine or foods? If so, please list. 您是否有對任何藥物或食物過敏? *
Your answer
Please provide any other relevant information of concern: 請提供其它需注意事項:
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Emergency Contact 緊急聯絡人資料
Name of Emergency Contact 緊急聯絡人姓名 *
Your answer
Phone of Emergency Contact 緊急聯絡電話 *
Your answer
Relationship with Emergency Contact 與緊急聯絡人的關係 *
Your answer
Statement, Waiver, and Signature 參加者聲明及簽名
I have completed the form truthfully. It is fully understood that if I misbehave, cause unrest, or become a distraction for other participants, US Zen and its staffs hold the right to evict me from its property without any warning nor reason given. 我對以上表格回答屬實,且於活動期間,要是我有任何不當行為、造成其他學員不安、或是干擾其他學員學習,美國禪學院及其相關成員不須有任何警告或解釋將我從活動中移除。 *
Required
It is fully understood that US Zen Institute, its relevant staffs and volunteers, are not responsible for any personal injury or illness, or any property lost, damaged or stolen during the retreat. 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,美國禪學院及其相關成員與義工不負任何法律責任、賠償責任。 *
Required
Participant Signature 參加者簽名 *
Your answer
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