Retreat Registration

RETREAT APPLICATION FORM

              活動期間(Time): May 25, 2012 7:00pm ~ May 28, 2012 3:00pm

      報名截止日期(Due Date): May 20, 2012

靜修法會，以參加全程者為優先錄取。早上五點起床，晚上十點休息。靜修期間止語，不可外出或接電話，必須遵守每天的作息，若因故無法隨眾時，請經主持法師許可。因名額有限，報名後，若臨時因故不能參加時，請儘早通知本寺，以便後補者遞補。

Those who attend the entire retreat will get the first priority. Participants, will get up at 5:00am and sleep at 10:00pm. Participants should observe silence, are not permitted to go outside the temple, make phone calls or send faxes. Please follow the daily schedule. If you are not able to attend the retreat after registration, please notify us as soon as possible, so that standby applicant can attend.

姓名(中文)： Name(English):	性別： Sex:	生日： Birth Date:
住址： Address:
電話 Phone(W):(        )_______________     Phone(H):(        )__________________    E-mail:_________________________              Fax# (         )__________________	職業:： Occupation:
靜修期間，緊急狀況之聯絡人                                               姓名                                        電話 In case of emergency, whom would you like us to contact?　 Name___________________ Phone:(    )________________

1.  你是否參加全程靜修活動？                                                                是 Yes □　　否  No □

Will you attend the whole retreat?

1.  如果不是，你願意參加那幾天？                                                         

If not, please circle the date you’ll attend.       __________________________________________________________                                        

1.  你參加過德州佛教會的靜修活動嗎? 如果是，請寫出上次參加日期。

      Have you ever attended any retreat in this center? If yes, specify when was the last time?

是Yes □   否 No □      日期Date:________________________

1.  你參加過其他道場的靜修活動嗎? 請寫出時間、地點和活動日數。

      Have you ever attended any retreat elsewhere? Please specify date, location, and how many days.

是Yes □  日期 Date:_____________地點 Place:___________________________日數 Days:________

否 No □

1.  你現在服用任何藥物嗎?是否有高血壓、糖尿病 、心臟病等病症，傳染性肝炎，或其他健康問題? 如果是，請說明

      Are you under medication? Do you have high blood pressure, diabetes, heart disease, hepatitis or other disease?

      Specify if yes.

是Yes □ ____________________________________________________，否No □

1.  費用：會員每日$20元/非會員每日$40元。

Fee :    Member $20/day / Non-member $ 40.00 /day

經本人謹慎閱讀 ，並了解此靜修法會之規則 ，本人完全同意遵守。

I have read and understood all the rules. I will abide by all instructions during the retreat.

簽名 Signature:_____________________________________ 日期 Date:_______________________