Retreat Registration

Monthly Half-Day Zen Retreat
with the Most Ven. Sunyananda Dharma

When:
December 12th 2015 (Saturday)
Arrival Time: 7:30am | Start Time: 8:00am
End Time: 12:00pm

Where:
Tu Bi Temple
1614 White Avenue,
Kansas City, MO 64126

Registration Fees:
General Registration: $50*
UBC Sustaining Supporters: No Cost
UBC Regular Supporters: $25

Retreat Application/Registration

Name *

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Last

Email *

Phone Number *

Address *

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Note: Participants may find some aspects of the retreat physically or emotionally demanding. In order to help maintain a safe environment for you and others, we ask the following questions. The following information will be kept confidential. It is requested solely in the event of an emergency.

Do you have any known physical or mental condition that could affect your ability to participate in the retreat?

Select One *

If your answer is yes, please summarize briefly, and, if applicable, provide the name of your health care practitioner who we may contact in the event of an emergency: *

Please list any critical medications you take on a regular basis, and dosages: *

Please list any critical food, drug, or environmental allergies you may have: *

In case of accident or serious illness, whom should we notify?

Name *

First

Last

Relationship *

Primary Phone Number *

Secondary Phone Number *

Address *

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State

Zip Code

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Release

Participants may find some aspects of the retreat program physically or mentally demanding. The program does include some physical work and a vigorous daily schedule. I may freely decline to participate in any work that in my sincere judgment is dangerous to my health. I realize that I may consult with a teacher at any time to resolve any difficulties I might have. I will not leave the retreat grounds during the program without consulting with a teacher.

I agree to release the United Buddhist Church Inc., Tu Bi Buddhist Cultural and Social Services Center Inc., their agents and affiliates from liability from any injury I suffer and to indemnify the same for any injury to others caused by me.

By entering your full legal name below you are signing in agreement to this document.

Signature (Enter Full Legal Name): *

Submit

*: A limited number of scholarships based upon a floating scale may be available, please contact Most Ven. Sunyananda for further information.

Monthly Half-Day Zen Retreatwith the Most Ven. Sunyananda Dharma

When:​December 12th 2015 (Saturday)Arrival Time: 7:30am | Start Time: 8:00amEnd Time: 12:00pm