Register for a Gateless Gate Zen Center YMJJ

Please complete and submit the form below to register for this retreat. For your records, a copy of your submission will be emailed to you at the address you provide below. Questions or comments? Please contact Head Dharma Teacher Janet Griswold or Director Matthew Tenney.

Tell us about yourself (* required fields) First Name* Last Name* Street Address 1* Street Address 2 City* State* Zip Code* E-mail Address* Phone* (e.g., 352-123-4567) Date of Birth (e.g., 12/22/1957)

Retreat Fee Schedule The retreat starts Friday and ends Sunday afternoon. $30.00 per day for Dharma Teachers. $90 full retreat. $40.00 per day for members of the Kwan Um School of Zen. $120 full retreat. $50.00 per day for non-members. $150 full retreat. Select this box to be considered for a reduced fee. Click here to pay online via Paypal. (Browser will open a new window).

Additional Info Directions to the retreat area and retreat schedule will be sent to you upon receipt of your completed registration form and deposit. As an alternative to submitting this form online, you may print it, complete it by hand and send it and a deposit of 50% of the total cost (check or money order made payable to "Gateless Gate Zen Center") to Director, Gateless Gate Zen Center, 1208 NW 4th Street, Gainesville, FL 32601

Person to contact in case of need
Full Name*
Relationship*
Phone* (e.g., 352-123-4567)

**NEW! IMPORTANT!** Select the retreat(s) that you wish to register for.

Jan. 9-11, 2009   Feb. 20-22, 2009   July 10-12. 2009   Oct. 2-5, 2009

Please answer the following questions

1. Do you have any previous experience with meditation techniques, therapies or healing practices? No Yes

If yes, please provide details.

2. Do you have any psychological health issues that currently require you to take medication? No Yes

If yes, please provide details.

3. Do you have any physical health issues that require specific care? No Yes

If yes, please provide details.

4. Do you have any dietary restrictions or allergies that our kitchen needs to address? No Yes

If yes, please provide details.

You may make additional comments or pose questions in the space below.

I hereby acknowledge that I have carefully read and understood the questions above and filled them out completely and honestly. I agree to stay on the retreat site and to abide by all the rules and regulations for the duration of the course. I realize a meditation retreat is a serious undertaking that will require my full mental and physical health and I affirm that I am fit to participate in it. I hereby certify that the above information is true and correct to the best of my knowledge. I further acknowledge and agree that I relieve the Gateless Gate Zen Center and its affiliates of liability and responsibility for my conduct and well being during the retreat and my presence on their property or in their facilities. I know that I am fully responsible for all my actions and conduct. At no time am I expected to do any thing that I consider against my best interests. Selecting this box indicates your acceptance of and agreement with the above statements.