Pagoda Phat Hue Retreat Application

Complete the information requested below, then click the “Submit Application” button at the bottom of the form. Please fill in all applicable information. Many questions are required by law and will remain confidential.

Retreatant Information

1. First Name(required)
2. Last Name(required)
3. Middle Initial
4. Email(valid email required)
5. Address(required)
6. City(required)
7. Country(required)
8. State/Prov(required)
9. Zip/Postal Code
10. Day Phone(required)
11. Evening Phone

General Information

1. Gender
2. Male Female
3. Year of Birth (YYYY)(required)
4. Occupation
5. Intended length of stay - For accurate billing information and scheduling procedures please specify which weeks you would like to attend.
6. Week 1 (June 20 to 27) Week 2 (June 27 to July 4) Week 3 (July 4 to 11) Week 4 (July 11 to 18) All four weeks (June 20th to July 18th)

Tell Us About Your Practice

1. Teacher Led Retreats - list dates and teachers of previous insight meditation retreats (7 days or more):(required)
2. Self Retreats - list dates, style of practice, duration and locations of any intensive self retreats:(required)
3. Other Traditions - list dates, teachers and duration of retreats in other traditions:
4. Please describe your current daily practice: (required)

Medical Questions

1. Are there any medical or psychological conditions that you feel are important for us to know about to better understand your needs regarding this retreat?(required)
2. Meditation retreats can at times be psychologically and emotionally stressful. In the event of a psychological emergency, do you have a therapist or psychiatrist that we could contact?
3. Yes No
4. Name:
5. Office phone:
6. Emergency Phone:
7. How well do you handle stress in your life? Are there recent circumstances (eg. loss of a loved one, illness, fasting, substance abuse, prolonged depression) or past history (eg. serious attempt to take your life) that might affect your retreat? (required)
8. Do you have any experience from past retreats or from stressful psychological challenges you have faced that would help you work with these issues?(required)
9. Do you have any history of physical illness or limitations that might be aggravated by or interfere with sitting and walking meditation?
10. Yes No
11. Do you have any physical limitations that would prevent you from participating in the daily work period?
12. Yes No
13. Intensive meditation may affect how your body and mind interact with medications, herbal or other treatments. Please consider consulting your health care provider to determine any potential complications. If it is helpful to advise us regarding your medications/supplements — so that we can address any needs or circumstances that may arise — please list them and the daily dosage:(required)
14. Our capacity to support ongoing medical needs is very limited. Do you have any such needs that would require leaving during your retreat?
15. Yes No
16. Do you have any serious food allergies?
17. Yes No

Silence, Personal Retreat & Intention

1. There is not the usual retreat structure at Pagoda Phat Hue. Have you thoroughly reviewed the Pa Auk Sayadaw practice guidelines?
2. Yes No
3. Pagoda Phat Hue retreatants need to be self-sufficient and disciplined, maintaining a steady schedule of intensive practice. There are usually two dharma talks per week and two interviews with teachers are required each week. Is this sufficient support for you? (Note: Some teachers may schedule more interviews and dharma talks than this.)
4. Yes No
5. Please describe the method of practice you would like to follow (eg. insight meditation, lovingkindness meditation, etc.):
6. The Pagoda Phat Hue offers some financial assistance for those who would be otherwise unable to attend. Are you interested in more information about this?
7. Yes No

References

1. Do you have a teacher who is most familiar with your practice?
2. Yes No
3. May we contact her or him?
4. Yes No
5. Teacher's contact information:
6. Where did you hear about Pagoda Phat Hue?
7. I understand that if my application for a personal retreat at Pagoda Phat Hue Seminar and Retreat Center is approved, I must provide on arrival the name and contact details of an emergency contact person in order to attend the retreat. I will not be allowed to participate unless I have done so. Pagoda Phat Hue will make every effort to communicate with this person in the event of an emergency. This person is someone who can either collect me from Pagoda Phat Hue retreat center or help to make transportation arrangements if I need to leave the retreat early.
   
   I further understand that participation in Pagoda Phat Hue Seminar and Retreat Center programs is at the discretion of the teachers and Pagoda Phat Hue administration at all times. If, in the opinion of Pagoda Phat Hue Seminar and Retreat Center, I am unable to continue to participate productively in the retreat, I may be asked to leave.
   
   I confirm that all of the above information is correct to the best of my knowledge and that I understand the practice guidelines and requirements. If at any time my circumstances change, I will inform Pagoda Phat Hue.
8. I have read and understand the above stated terms and conditions.

 

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