Dharma School Registration and Release Form 2004 / 2005


Youth Name (s)
Parent Name (s)

E-mail address

Street Address
CityStateZip

Youth’s Social Security # (opt.)Phone
Birth dateGrade

For student to fill out:

I understand that this is a Buddhist Sunday School for kids and I want to have some fun while learning to do Buddhist practice.

Yes
No

I am years old. I have been learning about Buddhism at home and/or at a temple.

Yes
No

Please visit Dharma School before making up your mind to register. Registration is only open in the beginning of each term, so that there can be stable and comfortable classes.

For parents to fill out: Pick One

I am a current Dharma Rain Member, and I am sending my Dharma School registration fee of $20 for the year.

I am a Still Point Subscriber, and I am sending my Dharma School
registration fee of $20 for the year.

I want to become a Still Point subscriber, and I am sending my Dharma School registration fee of $20, and my subscription fee of $12 for the year. If I am interested in Dharma Rain membership, I will fill out a membership form, which includes a Still Point subscription.

Please note: Payment options will be provided on the next page, after submitting this form.

In case of emergency please notify:

Name
Phone
Relationship

Alternate
Phone
Relationship

Does the youth have medical insurance coverage? Yes / No
Name of Primary Care Physician
Name of ProviderPhone
Plan
Account #
Does the youth have dental insurance coverage? Yes / No
Name of Dentist
Name of ProviderPhone
Plan
Account #

TREATMENT:
Does the young person have a medical condition that a doctor or medical professional should be informed of in case of an emergency? Please be specific.

Drug or food allergy?


Chronic illness or condition, physiological or behavioral?


Need to take regular medication?


Other?

RELEASE:

Please mark each item according to how they aply to your child.

  1. My child may be given regular over-the-counter medications such as aspirin, Tylenol, or cough medicine by the staff while at the activity or camp.
    Yes / No
  2. has prescription medication that should be self-administered as per physician’s directions.
    Yes / No
  3. has prescription medication that should be administered by adult staff member as per directions on medicine.
    Yes / No
  4. may be given any and all medical treatment deemed proper and necessary by an attending physician in case of emergency.
    Yes / No

I am the legal guardian/parent of the youth listed above. He/she/they have my permission to participate in the activities of Dharma Rain Zen Center’s Dharma School. I have filled out this form fully and accurately to the best of my knowledge. I have read the above release, crossed out any and all passages that are not acceptable and agree to release Northwest Zen Sangha, Dharma Rain Zen Center, Great Vow Zen Monastery and the staff of the Dharma School and Mandala on the Mountain Dharma Camp from any liabilities that might accrue from reasonable and normal activities during the time my child in their care. I have had all questions that I may have answered to my satisfaction. I will stay aware of the curriculum of the Dharma School so that I may support my child’s growth in understanding. I believe he/she is prepared to participate fully and have a good time.

I agree in full with the preceeding statement: Yes / No

Full Name, Custodial parent or guardian :
Date: