City Center Residential Volunteer Application

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Page 1

Intended Dates of Stay

Note: Arrival date must be on a Monday. Departure date must be a Saturday or Sunday. Date format is: Month/Day/Year

Arrival Date:

Must be on a Monday.

Departure Date:

Must be on a Saturday or Sunday.

Personal Information

Fields marked with an asterisk (*) are required.

First Name

Last Name

Email Address

Email Type

PersonalWorkAlternate

Please choose the best phone numbers for you to be reached at

Mobile

Household

Preferred

MobileHousehold

I identify my gender as (for housing purposes)

What gender pronoun do you go by (i.e. he/him, she/her, they/their or something else?)

Date of Birth

MM/DD/YYYY

Address

Mailing Street

Mailing City

Mailing State/Province

ZIP/Postal Code

Mailing Country

Emergency Contact Information

Emergency Contact Relationship

First Name

Last Name

Phone

Alternate Phone

Address

City

State/Province

ZIP/Postal Code

Country

Medical Contact Information

Physician First Name

Physician Last Name

Physician/Provider Phone

Health Insurance Company Name

Member/Policy Number

Group Number (if one)

Page 2

Please answer the following questions. This information will remain confidential.

Q & A

What is your interest and experience with meditation and Buddhist practice?

Have you ever lived in an intentional or spiritual community? If so, please describe your experience?

Do you have any medical problems that would affect your meditation practice or work practice ability at Zen Center? If so please describe.

Do you have a history of mental illness?

Have you ever been hospitalized? If yes, please explain and include dates.

Are you currently taking any prescribed medications?

YesNo

Please specify your medications.

Is there any reason why you cannot continue to take your prescribed medication during your stay at Zen Center?

Have you undergone treatment for alcoholism or drug addiction? If yes, please give dates of treatment.

Is there anything else that we should know about?

Please briefly describe your work history / professional background.

SFZC is committed to promoting diversity, equity, inclusivity and accessibility (DEIA). This could include study groups related to systemic racism, equity for LGBTQI, etc. Are you willing and open to engage in the training, study and practices the temple offers on these topics?

YesNo

City Center is a vegetarian environment, with meals offered Monday through Saturday and an open kitchen on Sunday. Do you have any specific dietary needs or restrictions?

Once your residential volunteer stay at City Center is over, what is your exit plan? Do you have the financial means to support your travel to your next location?