Bon​ ​Shen​ ​Ling

Emergency​ ​Contact​ ​Information

Please​ ​fill​ ​out​ ​and​ ​return​ ​to​ ​retreat​ ​manager​ ​by​ ​08-26-17​​ ​(via​ ​email​ ​if​ ​possible,​ ​to​ ​suzanne@bonshenling.org​​ ​)

Retreat​ ​Title: Six​ ​Lamps​ ​Teaching

Retreat​ ​Dates: Sept​ ​1-Sept​ ​4,​ ​2017

Your​ ​name​ ​(print):​ ​ ​ ​ ​ ​Sam​ ​Blake

Emergency​ ​contact​ ​name​ ​&​ ​relationship​ ​to​ ​you​ ​(spouse,​ ​child,​ ​etc.):​ ​ ​Elke​ ​Young:​ ​partner

Emergency​ ​contact​ ​address:​ ​4137​ ​49th​ ​ST​ ​APT​ ​3F​ ​Sunnyside,​ ​NY​ ​11104

Emergency​ ​contact​ ​phone​ ​#’s (cell):​ ​ ​ ​ ​ ​ ​ ​310​ ​883​ ​5005

(home):​ ​ ​ ​ ​ ​____________________________________

(work):​ ​ ​ ​ ​ ​_____________________________________

Do​ ​you​ ​have​ ​any​ ​medical/psychological​ ​issues​ ​that​ ​we​ ​should​ ​be​ ​aware​ ​of?
If​ ​yes,​ ​please​ ​list:​ ​None._______________________________________________________________________
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List​ ​Current​ ​Medications:

None._______________________________________________________________________________________
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List​ ​allergies​ ​to​ ​medication​ ​&​ ​food:​ ​(please​ ​note,​ ​special​ ​dietary​ ​needs​ ​such​ ​as​ ​vegan​ ​and​ ​gluten-free​ ​cannot​ ​be
accommodated)None.__________________________________________________________________________
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If​ ​this​ ​form​ ​does​ ​not​ ​provide​ ​you​ ​with​ ​enough​ ​space​ ​to​ ​share​ ​the​ ​information​ ​you​ ​wish​ ​to,​ ​please​ ​provide​ ​an
attached​ ​second​ ​page.​ ​ ​Please​ ​feel​ ​free​ ​to​ ​contact​ ​the​ ​retreat​ ​manager​ ​with​ ​any​ ​questions​ ​or​ ​concerns.
Return​ ​via​ ​email,​ ​or​ ​postal​ ​mail,​ ​by​ ​08/26/17,​ ​to:​ ​ ​Suzanne​ ​Bird,​ ​18​ ​Society​ ​Hill​ ​Way,​ ​Tinton​ ​Falls,​ ​NJ​ ​07724

The​ ​information​ ​you​ ​provide​ ​will​ ​be​ ​held​ ​confidentially​ ​by​ ​the​ ​retreat​ ​manager​ ​and​ ​only​ ​shared​ ​in​ ​the​ ​event​ ​of​ ​an
emergency.​ ​ ​It​ ​will​ ​be​ ​shredded​ ​after​ ​the​ ​retreat.​ ​Thank​ ​you!