12/23-25/2016 Mindfulness of Breaths @TOE
Name
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中文姓名
Chinese Name
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Address 地址
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中文
Chinese
English
Other language
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Home Phone Number 電話 (家)
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Cell Phone Number 手機
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Email Address 電子信箱
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Age 年齡
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Highest Education 學歷
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Gender 性別
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Occupation 職業
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I can attend 我能参加
I can only attend from Day ___ to Day ___,我只能参加____日至____日
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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
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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)
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Medicine or foods you are allergic to are: 您對任何藥物或食物過敏?
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Please provide any other information to take into consideration:請提供其它需注意事項:
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Have you ever practiced meditation before?您曾修持過禪修嗎?
If yes, please answer the following question 如回答是,請回答下一個問題
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Who are the meditation Instructors ? 禪修指導老師
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Have you ever participated a meditation retreat that is over 3 days?您曾參加過三天以上的禪修嗎?
If yes, please answer the following question 如回答是,請回答下一個問題
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Place of the meditation retreat 禪修地點
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緊急連絡人中文姓名
Emergency Contact Chinese Name
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Emergency contact person phone number (Daytime)緊急連絡人電話
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Emergency contact person phone number (Cellular) 緊急連絡人電話 (手機)
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Relationship with Emergency contact person 與緊急聯絡人的關係
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Emergency Contact Full Name
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Waiver of liability 參加者聲明
It is fully understood that BAUS and/or Temple of Enlightenment 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,美國佛教會及大覺寺不負任何法律責任、賠償責任。
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Signature 參加者簽名
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Date 日期
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