Please first type the number you see above in the text box* : 

Name*                                     :

Street Address                         :

Street Address (cont)              :

City                                         :

State/Province                        :

ZIP/Postal Code                      :

Country                                  :

Work Phone*                           :

Home Phone                           :

Cell Phone                               :

Email Address                          :

Applying for month*                  :

How are you going to attend?

                Full time

                   Part time

                   Short time

Please describe                             :  

Please provide emergency contact information:

Name                                            :

Work Phone                                 :

Home Phone                                :

Cell Phone                                    :

Are you a member?  Yes No

If so, how long?                          

Have you become student of Sensei Ross? Yes No

If any other teacher, please provide name:

In the last 12 months, have you been turned down for sesshin?

Yes No

Which sesshin?                                   

Which sesshins have you attended in the last year?

Sesshin fees must be submitted before the opening ceremony : Members: $35/day Non-members: $50/day

Acceptances: If you have not been contacted five days before sesshin to the contrary, you have been accepted for sesshin. If this

is your first sesshin at the CZC, please call after submitting this application to get information for first-time attendance.

Clothing: In addition to a well-made brown zazen robe, bring dark, solid-colored clothing for work and loose, ample pants or shorts (no very

short or tight shorts) and shirt or blouse (no tank tops or printed T-shirts) for use during the exercise period. Pure white, light or bright colors,

and patterned clothing are not appropriate during sesshin (no white socks, please). Nor should one wear such clothing underneath, if it is visible

at the neck or ankles. Please bring soft-soled shoes for use on the covered porch.

Medical: Answer the following in detail, regardless of whether you have done so for a previous sesshin. All information should be current,

specific, and clearly stated. This information will be kept confidential.

Briefly describe any medical or psychiatric conditions you have that require care or medication & list any prescription medications you are currently taking:

Are you in psychotherapy at this time?

Yes No

List hospitalizations or major surgeries you have had in the past five years:

May you need to sit in a chair during formal rounds during sesshin?

Yes No

Why do you need a chair?

Describe any other physical or mental condition, such as pregnancy, current infections, communicable diseases or chronic headaches, and list any dietary restrictions/requirements or food or other allergies that might affect your sesshin, and give some indication of their seriousness (for example, briefly describe the medical condition diagnosed or your reaction to the food).

By submitting this application, I electronically agree as follows:

1) I will finish the entire sesshin or portion of sesshin for which I have applied. 2) Waiver of liability: I understand that sesshin is a period of very intense traditional Zen training involving some 10 hours formal meditation per day during which participants may be frequently struck with the kyosaku (encouragement stick). In accordance with this understanding and in consideration for the Center’s accepting me to sesshin, I agree that neither the Chicago Zen Center nor any of its employees, officers, trustees, nor any person acting as sesshin monitor or otherwise supervising, overseeing, or conducting any aspect of sesshin shall be liable to me or to any other person for loss or injury suffered by me in connection with my participation in sesshin, whether or not such loss or injury is caused by any act or omission of the Center or those specified above.

Though certain security measures may be taken, I understand that no electronic communication is totally secure, and thus waive any expectation of an absolute guarantee of privacy if this application is submitted over the internet. (Note that paper applications either delivered by mail or in person are always acceptable.)

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