SFZC City Center Application FormWork Practice Apprentice (WPA), Zen Kitchen Apprentice (ZKA), and Mindful Activity Apprentice (MAA)

Page 1

Personal Information

Fields marked with an asterisk (*) are required.

First Name

Last Name

Date

Legal Name (if different)

Dharma Name

WPA

New WPA Returning WPA

Age

Date of Birth

MM/DD/YYYY

Phone Number

Alternative Phone number

Email Address

Date you wish to begin

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

Select which programs you would like to apply to:

Work Practice Apprenticeship (2 year program)Zen Kitchen Apprenticeship (3-6 month program)Mindful Activity Apprenticeship (3-6 month program)

If applying for the Zen Kitchen Apprenticeship or the Mindful Activity Apprenticeship, specify how many months you are applying for:

Address

Address

City

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)

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

Page 2

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

Q & A

It is a prerequisite to do at least 2 week guest student at City Center to do any of the apprenticeship programs.

Have you completed a minimum 2-week guest student stay?

YesNo

At which SFZC temple?

How long was the guest student stay?

Have you engaged in other practice 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, etc). If there is anyone at SFZC we can contact that may remember you from your previous stay, please let us know.

How did you hear about City Center?

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

YesNo

Please state the nature of the offense(s), when and where convicted, and disposition of the case. Convictions for marijuana-related offenses need not be listed.

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

Housing

Factors affecting sleep (Please describe)

Have insomnia or other sleeping disorderSnore

Other: please describe

Page 3

Medication

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

Health Record

	Yes	No
Do you have any long-term medical conditions, special needs, or a history of physical illness or limitations?
Have you had any 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 treated or hospitalized 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?

If you answered "yes" to any of the questions above, please describe them (below), including dates when applicable.

Date of your last tetanus shot

Personal Statement

Brief personal history.

Any previous experience in Buddhist or other meditation practices (other than SFZC).

Your interest in Zen and participating in the program at this time.

Intention in applying to practice at City Center at this time.

Interest in continuing to train SFZC beyond the time applied for, if any.

Work experience and skills (please include any form of medical training or experience).

Physical or mental health issues, including any noted under Health Record, above and how it might affect your Zazen and work practice.

Any other limitations that would prevent you from participating fully in the regular daily schdedule.

SFZC is committed to promoting diversity, equity, inclusivity and accessibility (DEIA). Are you willing and open to engage in the training, study and practices the temple offers on these topics? This could include study groups related to systemic racism, equity for LGBTQI, etc. Do you have any personal experience studying, responding to, or engaging with issues pertaining to DEIA?

Application Fee

Are you currently an SFZC Resident (at Green Gulch, City Center or Tassajara)?

YesNo

Payment of $30 may be paid here. Visa/MC only.

Name on Card

Card Number

MM

YY

Code

Billing Email

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