Green Gulch Farm, Farm and Garden/Land Application Form

Page 1

Personal Information

Fields marked with an asterisk (*) are required.

First Name

Last Name

Age

Date of Birth

MM/DD/YYYY

Email Address

Phone Number

Preferred gender pronouns (i.e. he/him, she/her, they/their or something else?)

Please upload a recent, cropped headshot. There is a free online cropping tool at cropp.me if you need it.

Please check which specific program(s) you are applying for:

Farm ApprenticeshipGarden/Land Stewardship Apprenticeship

Covid

Have you been vaccinated against COVID-19?

YesNo

Have you received a booster dose, if you are eligible?

YesNo

Will you be getting your booster dose by the time you arrive? Please give details.

What vaccine(s) did you receive? How many doses of each one have you received and what was the date of your last dose?

Please upload a copy of your CDC/National COVID-19 vaccination card or California Digital COVID-19 Vaccine Record/SMART Health Card here

Adults of any age with the following conditions are at increased risk of severe illness from the virus that causes COVID-19:

Cancer, chronic kidney disease, COPD (chronic obstructive pulmonary disease), Down syndrome, heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies), immunocompromised state (weakened immune system) from solid organ transplant, obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2), severe obesity (BMI ≥ 40 kg/m2), pregnancy, sickle cell disease, smoking, type 2 diabetes mellitus.

Do you have any of the conditions above?

YesNo

Please explain your risk factors below

Address

Mailing Street

Mailing City

Mailing State/Province

ZIP/Postal Code

Mailing Country

Emergency Contact Information

Emergency Contact Relationship

First Name

Last Name

Email Address

Phone Number

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)

Housing

Factors affecting sleep (Please describe). Note: Apprentices are generally housed in shared rooms.

Legal

Have you ever been convicted of a felony or serious misdemeanor?

YesNo

If yes, please state the nature of the offense(s), when and where convicted, and disposition of the case.Convictions for marijuana-related offenses that are more than two years old need not be listed.

Note: No applicant will be denied residency solely on the grounds of conviction of a criminal offense

Page 2

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

Q & A

Have you practiced at San Francisco Zen Center before?

YesNo

Please give dates and briefly describe (Tassajara/City Center/Green Gulch, summer or guest student/WPA/practice periods)

How did you hear about Green Gulch?

Health Record

	Yes	No
Do you have any long-term medical conditions, special medical needs, or a history of physical illness or limitations?
Have you had a serious illness or major surgery within the last 5 years?
Do you have any physical conditions or repetitive stress injuries that might limit your meditation or work practice?
Have you ever been hospitalized for a psychological condition?
Have you ever been treated for a psychological condition?
Are you currently receiving treatment for a psychological condition?
Do you have any dietary or health restrictions?
Do you have any serious allergies?
Do you have any hearing difficulties or impairment in vision?
Do you smoke, or use any kind of tobacco or nicotine products?
Do you have any history of substance abuse, drug or alcohol addiction, or eating disorder?
Have you participated in a recovery or treatment program for drug or alcohol addiction or an eating disorder?disorder?

Please describe below, including dates when applicable.

Date of your last tetanus shot

Medication

Please list below any prescription medication you are taking, including dosage and frequency of intake. (No need to include birth control or cosmetic prescriptions.)

Page 3

Personal Statement

Please write a brief personal history to help us get to know you a bit

Describe any previous experience in Buddhist or other meditation practices

What is your intention in applying to practice at Green Gulch at this time?

Tell us about your particular interest in the Green Gulch's Farm or Garden/Land Stewardship Apprenticeship

Describe your work experience and skills, including any farm or garden experience you have.

Are you interested in continuing in residential practice at Green Gulch Farm after this practice period?

YesNo

How long to you intend to stay in residence at Green Gulch Farm?

Describe your interests and/or intentions if continuing residential practice at Green Gulch Farm

Program Specific Questions

	Yes	No
Do you have any experience using hand or power tools?
Do you have any carpentry experience?
Do you have any plumbing experience?
Do you have any auto mechanic skills?
Do you have any experience driving large trucks?
Do you have any experience driving tractors or other heavy machinery?
Do you have any other specialized skills you think we should know about?

If you answered Yes to any question, please describe in more detail

Are you currently in a relationship?

YesNo

Please describe what expectations you have to spend time together during the apprenticeship program.

WORK PRACTICE REQUIREMENTS (Please see specific program schedules for more detail)

1. Following the schedule of morning and evening meditation, and morning and evening services of bowing and chanting as work allows.
2. Following the work practice schedule.
3. Attending Dharma talks, classes and ceremonies.
4. Attending crew meetings and Community meetings.
5. Participating in monthly one-day sittings, either in the Zendo or kitchen.
6. Refraining from drug and alcohol use.
7. Refraining from initiating any new sexual relationships.
8. Not leaving the Green Gulch watershed for the first month of the apprenticeship (except for emergencies).
9. Following the Green Gulch Residential Guidelines (Shingi).
10. Communicating with Crew Head and the Tanto or Director in a timely way if having difficulty with any of these requirements.

I agree to honor these requirements, have read the Green Gulch Residential Guidelines (Shingi) and agree to follow them completely.