Recent Photo 近照 PERSONAL RETREAT APPLICATION FORM

个人禅修申请表格

This form is to be completed by yogi applying for personal retreat with guidance or first time doing self retreat

without guidance.

欲申请个人禅修，包括需要或不需要褝修指导皆须填写此表格

I wish to apply for Personal retreat without guidance. Name of referee: _____________________________________

我想要申请 无老师指导之禅修 推荐人

Personal retreat with guidance by assistant teacher.

有老师指导之禅修

I wish to stay from dd/mm/yy _____________________ to ___________________ number of days: ________________

禅修日期(日/月/年) 天数

1. PERSONAL DETAILS 个人资料

FULL NAME 姓名	RELIGION 宗教
GENDER 性别	MALE / FEMALE 男 ／女	CURRENT AGE 年龄
NATIONALITY 国籍	OCCUPATION 职业
MARITAL STATUS 婚姻状况	SINGLE / MARRIED / DIVORCE 单身／已婚／已离异	DATE OF BIRTH 出生日期
HOME ADDRESS	TELEPHONE 电话	OFFICE : 办公室
住家地址	HOME : 住家
H/PHONE : 手机
EMAIL ADDRESS 电邮址
NRIC NO / PASSPORT NO and VISA EXPIRY DATE 身份证/护照号码和签证期限
NAME & ADDRESS OF BUDDHIST ORGANISATION ASSOCIATE WITH 参与之佛教团体及地址（如有）

2. MEDITATION INFORMATION 禅修资料

PLEASE STATE TYPE OF MEDITATION METHOD USED. 现在使用之禅修法门
FOR HOW LONG HAVE YOU USED THIS METHOD? 已使用此禅修法门多久？
WHO IS YOUR CURRENT MEDITATION TEACHER, IF ANY? 现在的禅修老师是谁？（如有）
DETAIL OF YOUR PAST MEDITATION RETREAT (minimum 10 days) 过去之密集禅修经验	Teacher老师 Type法门 Duration时间 When何时 1. 2. 3. 4. 5.

3. MEDICAL HEALTH DETAILS 健康状况

PLEASE STATE MEDICAL CONDITIONS (IF ANY) FOR EXAMPLE, HIGH BLOOD PRESSURE, KIDNEY / HEART PROBLEMS, ASTHMA, DIABETICS, ETC. 有任何严重疾病吗（如高血压、肾病、心脏病、哮喘、糖尿病等）	， YES是 NO否
DO YOU SUFFER FROM DEPRESSION, ANXIETY OR ANY OTHER MENTAL ILLNESSES 是否有忧郁症、焦虑或其他精神病状况？ IF YES, ARE YOU UNDER MEDICATION FOR SUCH ILLNESS? 若有，是否正在服药？	YES是 NO否 YES是 NO否

4. CONTACT PERSON IN CASE OF EMERGENCY 紧急联络人

NAME 姓名	MR 先生 MS 女士	HOUSE ADDRESS 住家地址
RELATIONSHIP 关系	EMAIL ADDRESS 电邮址
HOUSE TELEPHONE 住家电话	HANDPHONE 手机

RESUME ABOUT YOURSELF , include :-

Family background, Education background, Spiritual background, your personality and purpose of retreat at Appamda Vihari.

个人覆历，包括家庭、教育、宗教背景，个性及来正勤乐住禅修中心禅修的目的

I hereby declare and acknowledge that:-

I shall observe 8 precepts and practice noble silence during my stay in AVMC.

在正勤乐住禅林禅修期间我将遵守八关斎戒和圣默然的规约。

I have read, understand and shall strictly abide to the rules and regulations of AVMC.

我已经阅读及了解禅修期间之规则，並将遵守此规则。

I shall not hold AVMC responsible for my conduct that is contrary to its rules and regulations.

我同意正勤乐住禅林将无需为我不遵守规则的行为负责。

I shall not hold AVMC liable for any mishap due to my own negligence during my stay in AVMC.

我同意正勤乐住禅林将无需为因我自身疏忽造成的意外负责。

AVMC reserves the absolute right, in exceptional circumstances, to require a yogi to leave at 24 hours’ notice. This right shall be exercised in the best interest of AVMC.

正勤乐住禅林有权在特定情况下要求禅修者于24小时内离开禅林。此权利的行使主要为照顾禅林的整体利益。

PLEASE EMAIL THIS FORM TO : appamadavihari@gmail.com. NOTE: Tick where appropriate, write “N/A” where not applicable, delete the irrelevant option. FOR ENQUIRIES: email appamadavihari@gmail.com. APPROVAL: You will be notified through email when your application is approved.. DANA: All retreats expenses, building maintenance..etc survive on dana, we appreciate your donation, please download the dana form www.sayalaysusila.net (under retreat section) and submit to us.. MAP TO VENUE, Please visit www.sayalaysusila.net (under retreat section)

I _________________________, agree to abide by all the rules and carry out the daily duties during the retreat period.

本人______________________,同意遵守禅修期间的规约，並履行出坡的义务。

Signature:

签名：

_______________________

Date

日期: