Georgia Buddhist Vihara’s Youth Retreat 2012
(May 26,27,28 2012)
Retreat Application Form for Youth Summer Retreat
You must print and complete the following forms to apply for the summer retreat program. Please note that space is limited for 10 participants on a first-come, first-serve basis. This retreat is for males and females who are between 15 and 25 years of age. At this time, there are no facilities that support a co-ed retreat. The Georgia Buddhist Vihara hopes to be able to support a co-ed retreat in the near future.
All forms must be completed in full and must be submitted on or before May 1, 2012. You may deliver the forms in person to the Georgia Buddhist Vihara, you may mail the completed forms to the Vihara (3153 Miller Road, Lithonia, GA 30038), or you may scan and email completed forms to Justin Howell (justinhowell2112@gmail.com). An email confirmation will be sent once your application has been received.
Participant’s Name: ______________________________________________
Participant’s Age: _______________________
Parent’s/Guardian’s Name: __________________________________________________
Address: ________________________________________________________
Parent’s/Guardian’s Email Address: ___________________________________________
Home Phone: __________________________ Cell Phone: ___________________________
Business Phone: ____________________________________
Emergency Contact: __________________________ Phone: __________________________________
By signing below you are giving permission to participate in all activities related to the weekly retreat at the Georgia Buddhist Vihara. By signing below, you (as the participant) understand all requirements to participate in the retreat. By signing below, you are giving permission for the retreat participant to be transported in temple and/or personal vehicles of those who are acting as retreat coordinators while attending a retreat at the Georgia Buddhist Vihara.
_________________________ ______________________
Signature of Participant Date
_________________________ ______________________
Signature of Parent/Guardian Date
(if participant is under 18 years old)
Medical Information
Does the participant have any medical or health issues that we should be aware of? If so, please describe: ____________________________________________________________________________________
____________________________________________________________________________________
Allergies: ___________________________________________________________________________
Chronic disability or illness (past or present): _______________________________________________
Name of Family Doctor: ________________________ Phone: ________________________________
Insurance Plan Name: _______________________ Group Number: ___________________________
Member Number: _______________________________
Dietary Restrictions
Describe: _____________________________________________________________________________
Medications
I would like for the participant to be given the following medications:
Name of medicine: ____________________ What is the medicine used for: __________________
Quantity of be given: __________________ Times to be given: _____________________
All medicines should be clearly labeled with the participant’s name, name of medication, what it is to be used for, quantity to be given and time to be given. The Georgia Buddhist Vihara does not assume responsibility for administration of medicine beyond oral medications. In case of emergency, I hereby give permission to the physician named above, or, in his or her absence, to any other physician, to provide treatment.
_________________________ ______________________
Signature of Participant Date
_________________________ ______________________
Signature of Parent/Guardian Date
(if participant is under 18 years old)
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Georgia Buddhist Youth Retreat
(May 26,27 & 28)
Daily Schedule
- 5:00–5:30am – Wake Up, Coffee/Tea.
- 5:30–6:30 – Group Meditation
- 6:30–7:00 – Buddha Puja
- 7:00–8:00 – Breakfast (self-service)
- 8:00–9:00 – Vipassana Meditation
- 9:00–9:30 – Break, Coffee/Tea
- 9:30–10:00 – Meditation Instruction
- 10:00–10:30 – Walking Meditation
- 10:30–11:00 – Metta Meditation
- 11:00–11:30 – Buddha Puja
- 11:30–12:30pm – Lunch
- 12:30–1:30 – Work Period
- 1:30–3:30 – Sutta Discussion
- 3:30–4:00 – Break, Coffee/Tea
- 4:00–4:30 – Personal Reading and Reflection
- 4:30- 5:30- Abhidhamma session by Dr. Deeptha Jayaratne
- 5:30–6:00 – Prepare for Trip
- 6:00–7:30 – Temple Visits
- 7:30–8:30 – Atavisi Buddha Pujawa, Group Chanting (selected Sutra with English meanings) Metta Meditation
- 8:30–9:00 – Journal Writing; Prepare for Bed
- 9:00–Lights Out
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General Guidelines for Retreat Participants
What Not to Bring
- Do not bring illicit drugs, alcohol, or tobacco products.
- Do not bring personal computers, personal gaming systems, cell phones, mp3 players, electronic musical devices, radios, musical instruments, newspapers, magazines and secular books to the center. Buddhist reading materials will be provided.
- Do not bring clothing with distracting lettering.
- Do not wear perfumes or deodorants with strong scents.
- Do not bring pets.
What to Bring
- Flashlight
- Sleeping Bag, Pillow, Towel (shower facilities are available)
- Toiletries (soap, shampoo, toothbrush, toothpaste, razors)
- Bring a cup (for tea/coffee and water), a plate, and a spoon and fork for eating.
- Ear plugs if you are a light sleeper
- Personal meditation cushion if you prefer (We have plenty of zafus, zabutans, and benches for everyone)
- Modest clothing. (Even in the warmest of weather, tank tops and short shorts are not acceptable.) Do not bring t-shirts with commercial or political messages. You are requested to wear white clothing, if possible.
- Work gloves, cleaning gloves, breathing mask (if working outside causes breathing problems) for the work period.
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Family Sponsorship Form
- Each sponsoring family will need to arrive at the vihara by 6am on their designated day in order to prepare the morning meal for the monks and retreat participants.
- Sponsoring families will also be responsible for preparing the lunch meal.
- Sponsoring families will be responsible for preparing evening nutrition and leaving it for the participants to consume later in the evening.
- It is preferred that sponsors adhere to the following guidelines for providing meals during the retreat period:
- All meals should be vegetarian.
- Food for the morning meal should be light and consist of cereal, oatmeal, muffins, bagels, fruit, yogurt, or pancakes.
- Food for the lunch meal should be more substantial since this will be the primary meal until the next morning meal.
- Evening nutrition could consist of homemade juices, milkshakes, soup, etc. Please be mindful that retreat participants have taken the 10 precepts which stipulate that no solid, substantial food should be taken after noon.
Saturday, May 26
Danas & Evening Gilanpasa & Ata-visi Pujjawas will be taken care of by Mrs. Priyanga, Mrs. Sumudu & Mrs. Taniya & one or 2 Mothers will be there for the nights with the Girls
Sunday, May 27
Dr Unil Peraa family will provide the Daval Dana for Sunday & Flowers & Gilanpasa for the eve Ata-visi Pujawa on Sunday Morning.
Monday, May 28
Danas & Gilanpasa & Ata-visi Puja wasthu will be provided by Mrs. Roshini, Mrs. Upeksha & Mrs.Kumudini