Application for Retreat or Residency At Great Determination
(one application per person, please)
(one application per person, please)
The information submitted with this form is confidential and will be used only by the staff of Great Determination to help us accomodate you better.
Name (s)_______________________________________________________________________________________________________
Address_______________________________________________________________________________________________________
Phone Numbers_________________________________________________________________________________________________
Email address___________________________________________________________________________________________________
Driver's license or passport number__________________________________________________________________________________
Age____Date of Birth____________Gender M / F / Other (describe)_______________________________________________________
Primary Relationships____________________________________________________________________________________________
Companion Animals _____________________________________________________________________________________________
Occupation_____________________________________________________________________________________________________
Date and description of proposed visit _______________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
References, please list two to three people with their contact info who can vouch for you, include a Buddhist teacher if you have one:
1. Name, Relationship to you, Address, Phone numbers, Email ______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
2. Name, Relationship to you, Address, Phone numbers, Email
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
3. Name, Relationship to you, Address, Phone numbers, Email
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Emergency contact: Name, Address, Phone numbers, Email (this person should have information like your medical history, physician name and contact info, insurance company and policy number.)
_____________________________________________________________________________________________________________
Is there any medical information you would like to share with us in case of emergency?______________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Do you know and agree that Great Determination and its residents are not responsible for any illness, injury or accident that may
befall you? Yes / No
Please list any allergic reactions you have had (example: bee sting - difficulty breathing - emergency room)_____________________
_____________________________________________________________________________________________________________
Describe any dietary restrictions__________________________________________________________________________________
_____________________________________________________________________________________________________________
Do you use alcohol, tobacco or other substances?___________________________________________________________________
Do you agree to not use alcohol or tobacco or other substances other than presciption or OTC meds for medical purposes while at
Great Determination? Yes / No
Please continue to take any prescribed medications as directed while at Great Determination and if any medications have been prescribed for emergency treatment or are used as needed to treat conditions that may arise unexpectedly please have them available.
Please describe any media you routinely experience or use such as TV, Internet, Radio, Texting, Blackberry, Twitter, Email, and
Telephone____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Do you agree to discontinue or limit such media contact during your stay at Great Determination? Yes / No
Please describe any physical, mental or emotional challenges you have and how they could be accomodated to make your stay at
Great Determination beneficial. ___________________________________________________________________________________
_____________________________________________________________________________________________________________
Please tell us about your Buddhist studies __________________________________________________________________________
______________________________________________________________________________________________________________
Do you have a teacher? If so, whom? How long have you studied and practiced under this person’s guidance?____________________
______________________________________________________________________________________________________________
Do you do a daily meditation practice? If so, what meditation(s) do you do? Add any other information about your religious/spiritual
background that could be helpful.___________________________________________________________________________________
______________________________________________________________________________________________________________
Have you done any meditation retreats or long courses? Please describe.__________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
What precepts have you taken or would you like to take for your time at Great Determination?_________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Do you agree to abide by the Five Precepts as described below while at Great Determination? Yes / No :
1. Respecting life, I vow to avoid killing living things, and avoid harming anyone including myself through deed, word or thought. If I cannot share space with small creatures I will gently escort them out and release them.
2. Mindful of the needs of others, I vow to avoid taking what is not given, to avoid using what is not offered. I also agree to be careful and frugal with tools and supplies.
3. Recognizing that sensual desire fosters selfishness which obstructs discernment, and leads to vexation for others,
and myself, I vow to avoid sexual misconduct, to practice chastity while at the Hermitage. I agree to relate to everyone in a non-sexual way.
4. Realizing self discipline begins here I vow to avoid false speech, malicious speech, harsh speech and gossip. I agree to recognize and avoid idle chatter.
5. Respecting the clarity of mindful attention that is demanded to practice I vow to avoid intoxicants. Absolutely no alcohol or illegal substances are to be consumed while at Great Determination. I agree to avoid tobacco products and if I feel I cannot avoid them I will report to the abbot or her substitute and go off the land or leave as requested.
Do you have any questions or concerns about visiting Great Determination? _______________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Everything on this application is true and complete to the best of my knowledge. I authorize Great Determination to contact any of the people listed above to support this application. I give Great Determination permission to do a criminal background check with state and federal agencies, using information on this application, to the extent permitted by state and federal law. I agree to follow Great Determination’s guidelines, which I have read. I understand that failure to do so may result in termination of visit. I do not hold Great Determination Buddhist Practice Center and Hermitage responsible for any theft or loss of property or any accident or injury.
Signed_____________________________________________________Date_________________________________
Name (s)_______________________________________________________________________________________________________
Address_______________________________________________________________________________________________________
Phone Numbers_________________________________________________________________________________________________
Email address___________________________________________________________________________________________________
Driver's license or passport number__________________________________________________________________________________
Age____Date of Birth____________Gender M / F / Other (describe)_______________________________________________________
Primary Relationships____________________________________________________________________________________________
Companion Animals _____________________________________________________________________________________________
Occupation_____________________________________________________________________________________________________
Date and description of proposed visit _______________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
References, please list two to three people with their contact info who can vouch for you, include a Buddhist teacher if you have one:
1. Name, Relationship to you, Address, Phone numbers, Email ______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
2. Name, Relationship to you, Address, Phone numbers, Email
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
3. Name, Relationship to you, Address, Phone numbers, Email
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Emergency contact: Name, Address, Phone numbers, Email (this person should have information like your medical history, physician name and contact info, insurance company and policy number.)
_____________________________________________________________________________________________________________
Is there any medical information you would like to share with us in case of emergency?______________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Do you know and agree that Great Determination and its residents are not responsible for any illness, injury or accident that may
befall you? Yes / No
Please list any allergic reactions you have had (example: bee sting - difficulty breathing - emergency room)_____________________
_____________________________________________________________________________________________________________
Describe any dietary restrictions__________________________________________________________________________________
_____________________________________________________________________________________________________________
Do you use alcohol, tobacco or other substances?___________________________________________________________________
Do you agree to not use alcohol or tobacco or other substances other than presciption or OTC meds for medical purposes while at
Great Determination? Yes / No
Please continue to take any prescribed medications as directed while at Great Determination and if any medications have been prescribed for emergency treatment or are used as needed to treat conditions that may arise unexpectedly please have them available.
Please describe any media you routinely experience or use such as TV, Internet, Radio, Texting, Blackberry, Twitter, Email, and
Telephone____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Do you agree to discontinue or limit such media contact during your stay at Great Determination? Yes / No
Please describe any physical, mental or emotional challenges you have and how they could be accomodated to make your stay at
Great Determination beneficial. ___________________________________________________________________________________
_____________________________________________________________________________________________________________
Please tell us about your Buddhist studies __________________________________________________________________________
______________________________________________________________________________________________________________
Do you have a teacher? If so, whom? How long have you studied and practiced under this person’s guidance?____________________
______________________________________________________________________________________________________________
Do you do a daily meditation practice? If so, what meditation(s) do you do? Add any other information about your religious/spiritual
background that could be helpful.___________________________________________________________________________________
______________________________________________________________________________________________________________
Have you done any meditation retreats or long courses? Please describe.__________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
What precepts have you taken or would you like to take for your time at Great Determination?_________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Do you agree to abide by the Five Precepts as described below while at Great Determination? Yes / No :
1. Respecting life, I vow to avoid killing living things, and avoid harming anyone including myself through deed, word or thought. If I cannot share space with small creatures I will gently escort them out and release them.
2. Mindful of the needs of others, I vow to avoid taking what is not given, to avoid using what is not offered. I also agree to be careful and frugal with tools and supplies.
3. Recognizing that sensual desire fosters selfishness which obstructs discernment, and leads to vexation for others,
and myself, I vow to avoid sexual misconduct, to practice chastity while at the Hermitage. I agree to relate to everyone in a non-sexual way.
4. Realizing self discipline begins here I vow to avoid false speech, malicious speech, harsh speech and gossip. I agree to recognize and avoid idle chatter.
5. Respecting the clarity of mindful attention that is demanded to practice I vow to avoid intoxicants. Absolutely no alcohol or illegal substances are to be consumed while at Great Determination. I agree to avoid tobacco products and if I feel I cannot avoid them I will report to the abbot or her substitute and go off the land or leave as requested.
Do you have any questions or concerns about visiting Great Determination? _______________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Everything on this application is true and complete to the best of my knowledge. I authorize Great Determination to contact any of the people listed above to support this application. I give Great Determination permission to do a criminal background check with state and federal agencies, using information on this application, to the extent permitted by state and federal law. I agree to follow Great Determination’s guidelines, which I have read. I understand that failure to do so may result in termination of visit. I do not hold Great Determination Buddhist Practice Center and Hermitage responsible for any theft or loss of property or any accident or injury.
Signed_____________________________________________________Date_________________________________