JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Musangsa Retreat Application
*Please make sure to fill out all the required fields COMPLETELY so that the application can be processed promptly. IMPORTANT: This application will be received and approved by the Guiding Teacher before the applicant is admitted to any retreat program. The same applies to former retreat participants.*
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Full Name: Last/ First/ Middle
*
Your answer
Buddhist Name (if applicable)
Your answer
Contact Number (Mobile Phone or Phone Number)
*
Your answer
Address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Others
Select
Female
Male
Others
Select
Nationality or Country of Passport
*
Your answer
Marital Status
*
Single
Married
Select
Single
Married
Select
Occupation
Your answer
Retreat Entry Date on May & Jun
May 20th 2024.
Jun 1st 2024.
Jun 8th 2024.
Jun 15th 2024.
Jun 22nd 2024.
Jun 29th 2024.
Select
May 20th 2024.
Jun 1st 2024.
Jun 8th 2024.
Jun 15th 2024.
Jun 22nd 2024.
Jun 29th 2024.
Select
Clear selection
Retreat Entry Date on July
July 6th 2024
July 13th 2024
July 20th 2024
July 27th 2024
Select
July 6th 2024
July 13th 2024
July 20th 2024
July 27th 2024
Select
Clear selection
Retreat Entry Date on August
August 3rd 2024
August 10th 2024
Select
August 3rd 2024
August 10th 2024
Select
Clear selection
Retreat Exit Date
*
MM
/
DD
/
YYYY
Do you have any health issues or allergies?
*
Yes
No
Option
Yes
No
Option
If yes, please describe briefly.
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Phone Number
*
Your answer
Relation to Applicant
*
Your answer
Are You a current Kwan Um School of Zen Member?
*
Yes
No
Monk/Nun
Option
Yes
No
Monk/Nun
Option
If you are a member, or monk or nun in the KUSZ, name your Zen Center and Guiding Teacher.
Your answer
Please check one of the following that pertains to you.
5P
DTiT
DT
Sami
Samini
Bhikkhu
Bhikkhuni
JDPSN/ZM
None
KUSZ
5P
DTiT
DT
Sami
Samini
Bhikkhu
Bhikkhuni
JDPSN/ZM
None
KUSZ
Clear selection
Date of precepts or ordination (as applicable)
MM
/
DD
/
YYYY
If you are ordained as a sami/samini, bhikkhu/bhikkhuni or priest/priestess from a different tradition, please state tradition, temple address, teacher & ordination date.
Your answer
Programs at Musangsa are in English. Do you need translation into another language?
*
Yes
No
Option
Yes
No
Option
If you need translation into another language, please state below.
Your answer
What is your meditation experience? Please give details.
*
Your answer
From time to time, group photos are taken during programs at Musangsa. Do you give permission to Musangsa to allow your photograph to be taken during participation in Musangsa's programs? The photos will only be used to promote Musangsa's activities and will not be used for any other purpose or by a third party.
*
Yes
No
Option
Yes
No
Option
Do you give Musangsa permission for your email address to be stored in Musangsa's mailing list, so that we may notify you of future programs? Your email address will not be distributed to a third party.
*
Yes
No
Option
Yes
No
Option
By ticking the checkbox I certify that all of the above statements are true and complete to the best of my knowledge.
*
I agree.
Required
Date of Agreement
*
MM
/
DD
/
YYYY
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Musangsa.
Report Abuse
Forms
