Request for Stay at the Vermont Zen Center

Proposed dates of visit  
Reason for visit  
Full Name  
Street Address  
City  
State/Province  
Zip/Postal Code  
Country  
Phone  
E-Mail  
Are you a member of a Buddhist group?  
Do you have a Zen teacher? If so, who?  
Any special needs?  
Medical information we should know about?  
Name of emergency contact   
Emergency contact's phone number  
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