Embracing Simplicity Hermitage

41 Wisdom Lane, Hendersonville, NC 28739

828-338-2665

email info@embracingsimplicityhermitage.org

Application for Residency

Please print legibly in ink. Fax to 919-287-2473, or Mail to Embracing Simplicity Hermitage at the above address. If faxed, please call the Hermitage or e-mail to confirm receipt.

Please include a recent photo of yourself (may be faxed, emailed or mailed)

Name __________________________________________________________________________________________

Street __________________________________________________________________________________________

City, State, Zip___________________________________________________________________________________

Phone __________________________________________________________________________________________

Email __________________________________________________________________________________________

Fax____________________________________________________________________________________________

Sex M___ F___ Date of Birth __________________________ Age_______

Social Security or Identification number _________________________________________________________________

Driver’s License Number ___________________________________ State of Issuance _______ Exp. Date___________

When do you want to start your trial period? _____________________________________________________________

When do you want to start your actual residency? _________________________________________________________

When do you plan to leave? _________________________________________________________________________

Please describe your past experience with meditation, including retreats you have attended, type of meditation, length of time

you have been meditating. ________________________________________________________________________________________________

________________________________________________________________________________________________

Why would you like to be a long-term resident at Embracing Simplicity Hermitage?

________________________________________________________________________________________________

Please list any other retreat centers or sanghas where you have been a resident for any period of time. Include length of residency, name and telephone number of contact person, and reason for residency. Use back of page or attach another page if more space is needed.

_________________________________________________________________________________________________

Please indicate if you are interested in monastic ordination ___________________________________________________

Please indicate if you are interested in the MDh (Master’s in Buddhist Philosophy), or the DDh

(Doctorate in Buddhist Psychology) _____________________________________________________________

Please indicate if you are interested in the Dharmachariya (Dhamma Teacher’s Certification) __________________________

Please list work skills you have that could be useful to the Hermitage (for example, office skills, kitchen experience, gardening, construction, writing/editing etc.)

________________________________________________________________________________________________

Do you have any physical conditions that will limit your ability to participate fully in the activities of the Hermitage or that will require special diets or other accommodations? ___ Yes ___ No

If yes, please describe the condition and any accommodations that would be required. ________________________________________________________________________________________________

________________________________________________________________________________________________

If you have any pending legal problems or financial obligations or if you have a history of psychiatric illness, these must be discussed with the Hermitage before you begin any proposed residency. Please list pertinent details.

________________________________________________________________________________________________

Please describe in some detail how you have spent the past two or three

years (work, school, travel, etc.) ______________________________________________________________________

________________________________________________________________________________________________

References

References will be contacted and a police/criminal background check conducted before considering you for residency at the Hermitage.

Please list three references (not relatives). One should be a recent employment supervisor.

Reference 1

Name _________________________________________________________________

Address _______________________________________________________________

Phone _________________________________________________________________

Relationship_____________________________________________________________

How long has this person known you? ________________________________________

Reference 2

Name _________________________________________________________________

Address _______________________________________________________________

Phone _________________________________________________________________

Relationship____________________________________________________________

How long has this person known you? _______________________________________

Reference 3

Name _________________________________________________________________

Address _______________________________________________________________

Phone _________________________________________________________________

Relationship____________________________________________________________

How long has this person known you? _______________________________________

Financial Back-up

Please list the name of the person who will provide for you if you need to leave the Hermitage for any reason or if you are ill and require assistance. (If it is one of your personal references, just list the name.)

Name _________________________________________________________________

Address _______________________________________________________________

Phone _________________________________________________________________

Relationship_____________________________________________________________

Payment method: [ ] Check [ ] MasterCard [ ] Visa

Amount ______________________

Credit Card # __________________________________________________________________

Expiration Date mm/yy _________________________________________________________

Name on Card if different from above ______________________________________________

Billing address if different from above ______________________________________________

Check: Enclose your check with this form and send to

Embracing Simplicity Hermitage

41 Wisdom Lane

Hendersonville, NC 28739

Please complete and submit the Emergency Information Sheet (see next page).

Emergency Information Sheet This sheet must be on file for every resident.

Name_________________________________________ Date __________________

Person to be notified in the case of emergency:

Name ________________________________________________________________

Address______________________________________________________________

Telephone(s) ________________________________________________________

Relationship ________________________________________________________

If that person is unavailable, please notify:

Name ________________________________________________________________

Address______________________________________________________________

Telephone(s) ________________________________________________________

Relationship ________________________________________________________

Please list your next of kin if that person is not listed above:

Name ________________________________________________________________

Address______________________________________________________________

Telephone(s) ________________________________________________________

Relationship ________________________________________________________

*Embracing Simplicity Hermitage is not responsible for health problems and cannot incur hospital or physician expenses for any resident. You are solely responsible for your own health care (or lack thereof). Health insurance coverage must be valid in North Carolina.

Doctor's name ________________________________________________________

Doctor's telephone ___________________________________________________

*Are you covered by health insurance?____ Must be valid in North Carolina.

If yes, please fill out below.

Name of insurance company ____________________________________________

Person who is insured_________________________________________________

Relationship to you___________________________________________________

Their I.D. number_____________________________________________________

Group number__________________________________________________________

Medications you are taking.___________________________________________

______________________________________________________________________

Allergies to food or medication.______________________________________

______________________________________________________________________

Any underlying medical conditions that we or a doctor may need to know about?

______________________________________________________________________

Psychological History

Have you ever been diagnosed with a psychological condition (prolonged or serious depression, manic depressive illness, panic attacks or schizophrenia, etc.) or other emotional problems that Embracing Simplicity Hermitage should know about? If yes, briefly describe the diagnosis, treatment and dates. Please attach additional pages if needed.

Are you currently taking any medication(s) for physical or psychological conditions? If so, please list the medication(s) and the condition(s) being treated. Please attach additional pages if needed

Are you currently seeing a therapist or counselor?

Are there conditions in your life that might be placing you under severe stress (e.g. divorce, substance abuse or withdrawal, loss of a loved one, etc.)? If yes, please give details. Please attach additional pages if needed.

Have you ever been arrested or convicted of a crime? If yes, please describe. Please attach additional pages if needed.

Do you have any additional information that you would like to convey? Please attach additional pages if needed.

I, (full name) _______________________________________, have read and understand the Requirements and Terms for Residency at Embracing Simplicity Hermitage. I agree to abide by these terms and conditions, should I be accepted for residency. I understand that failure to do so may result in the termination of my residency.

I acknowledge that all the information included in this application is true and complete. I authorize Embracing Simplicity Hermitage (ESH) to contact any or all of the individuals listed above to support this application and give permission for ESH and/or its agents to do a criminal background check, using all information included in this application, with agencies from this state or any state or federal agency, to the extent permitted by state and federal law.

Print Name _______________________________________

Signature _________________________________________ Date ________________

[ ] I do [ ] I do not

consent to being photographed at Embracing Simplicity Hermitage for the purpose of its archival records.

[ ] I do [ ] I do not

consent to allow the said photographs to be used by the Hermitage in its promotional and educational materials, such as brochures, testimonials, newsletters, and on its web site.

Print Name___________________________________________

Signature ____________________________________________ Date____________________

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