New York Zen Center - Retreat Health Questionnaire and Waiver of Liability
WHOLEHEARTED SESSHIN 2023: SUMMER SILENT RETREAT
At the Garrison Institute
August 2-9, 2023

We are delighted that you'll be joining us for this retreat!

In order to ensure we can provide the care and support you need on retreat, which can be stressful emotionally and physically, we ask the following medical and emergency contact questions.

This information will be held confidentially by NYZC staff and staff holding the retreat. Teachers and retreat support will see this information, otherwise it will be kept strictly confidential except as noted below.

Additionally, NYZC requires all retreat participants to take a rapid (home test) covid test 24 hours prior to the start of the retreat, and inform us if you receive a positive test result.  

Please indicate your agreement below.
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First name: *
Last name: *
Phone number: *
Email address: *
EMERGENCY CONTACT PERSON

- In case of emergency, or if you need to leave the retreat early, this is the person we will contact.

- The emergency contact person should be someone who can either collect you from NYZC or the retreat venue, or help to make transportation arrangements if you need to leave the retreat early.

- If you are coming from overseas, it is fine to provide an overseas emergency contact person.

- We cannot allow you to participate in the retreat unless we have your emergency contact person's name and contact details.


Please provide the following Emergency Contact information:

Emergency Contact Person - Name

 *
Emergency Contact Person - Relationship *
Emergency Contact Person - Email Address *
Emergency Contact Person - Daytime Phone Number *
Emergency Contact Person - Evening Phone Number *
PRESCRIPTION MEDICATION INFORMATION

We ask for this information so that, in the event of an emergency, we can inform the Emergency Medical Services personnel on your behalf. Teachers and retreat support will see this information, otherwise, it will be kept entirely confidential.

What prescription medications are you taking now - or have taken in the past six months, and what is the condition being treated?

Please list the name(s) of all medications and the conditions(s) being treated.
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Are you allergic to any medication?
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Do you have any serious allergies (e.g. bee stings, nut allergies, etc.)?  If yes, please specify and explain how we should best respond in the event of a medical emergency.
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What current or past medical or physical conditions are important for us to know about? *
Do you have any specific physical limitations that need to be considered in relation to your housing, or that would affect your ability to participate in sitting or walking meditation? *
Do you need a chair for sitting meditation? *
Do you have hearing loss (even mild) that sometimes requires assistance?  If so, please describe. *
Do you have a healthcare background, and are you willing to assist in the case of an emergency? *
NYZC requires all participants to take a rapid (home test) covid test 24 hours before the program start.  Please indicate your agreement to the following statement, by checking the Yes box below. "I agree to take a covid-19 rapid test 24 hours before I come to the retreat and inform NYZC if I receive a positive test result." *
Have you attended a retreat with NYZC before?
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Have you attended a meditation retreat elsewhere before? 
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NYZC In-Person Retreat Participation

Release & Waiver of Liability

Updated: 2/20/23

 

I voluntarily agree to participate in New York Zen Center for Contemplative Care’s (NYZC) in-person retreat activities and assume all risks. If I have any concern about my ability to safely participate in any retreat activities, I will notify a staff member immediately. I understand there may be unanticipated risks during such activities. I hereby assume all risks of injury to me and my property, which may be sustained in connection with activities undertaken while at NYZC.

I hereby release NYZC, its affiliates, employees, agents or volunteers, from all actions, claims or demands that I, my assignees, heirs, distributees, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my participation in this program.

I acknowledge that intensive retreat practice can be physically and psychologically challenging. I understand that NYZC is not expected or able to provide medical and/or psychological care, and agree that no NYZC representative will diagnose or treat any condition or illness.

In the event a representative of NYZC determines that I may need professional medical and/or psychological attention, I agree that NYZC has the authority and discretion to contact 9-1-1 emergency services, or any other medical professional, as determined by NYZC, and to provide my contact information to said entities. Any costs incurred for health services are my responsibility and not the responsibility of NYZC.

NYZC strives to provide a safe, peaceful and efficient environment for meditators. It is with regret that we find, at times, the need to turn someone away prior to retreat or ask them to leave. Please know that we take great care in such situations – the discernment process is thorough and always with the intention to protect the majority of those who practice here.

I understand that participation in NYZC retreat programs is at the sole discretion of NYZC at all times and I may be asked to not participate or leave the program if deemed necessary by NYZC.

By participating in any NYZC retreat activities, I affirm that I have sought medical advice regarding my physical and mental fitness or am certain of my ability to participate in the NYZC retreat activity, event, or program I have registered for. If you have any pre-existing medical conditions (e.g., asthma, diabetes, heart disease), physical injuries, weakness, are pregnant, post-natal or post-surgery, or have any mental conditions that may be triggered (e.g., anxiety, PTSD) you should consult with your doctor first before engaging in any NYZC activities. Please communicate and inform us immediately if at any point you do not feel well during your participation in NYZC activities.

I understand that retreat support, relevant staff and teachers may share information to best support me while I am on retreat.

I understand that I must provide the name and contact details of an emergency contact person in order to attend the retreat, and that I will not be allowed to participate unless I have done so. NYZC will make every effort to contact this person in the event of an emergency. This person is someone who can either transport me from NYZC or help to make transportation arrangements if I need to leave the retreat early.

I acknowledge and agree that I am responsible for all of my personal property during the Retreat and that NYZC is not responsible in any way for such property whether it is lost, stolen or damaged.

I grant and convey unto NYZC all right, title, and interest in any and all photographic images, video or audio recordings made by NYZC during the Program, including but not limited to royalties, proceeds, or other benefits derived. I authorize NYZC to use such images, words, and likenesses for marketing, on websites, and for any other legitimate purpose.

This agreement shall be governed by the laws of the State of New York. The venue for any legal action shall be the state or federal courts of the Borough of Manhattan in the City of New York in each case located in the Borough of Manhattan in the City of New York.

I have read the NYZC In-Person Retreat Participation Release & Waiver of Liability agreement and I fully understand its contents. I sign it of my own free will and agree to all terms. I am of legal age and accept the above disclaimer, release, and waiver of liability.

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