Embracing Simplicity Hermitage

41 Wisdom Lane, Hendersonville, NC. 28739

info@embracingsimplicityhermitage.org

828-696-1638

Application for Residency

Please print legibly in ink and fax to 800-894-0197, or mail to Embracing Simplicity Hermitage at the above address.

If faxed, please call the Hermitage or e-mail kaye@embracingsimplicityhermitage.org 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___ 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 indicate if you are interested in monastic ordination _________________________________

Please indicate if you are interested in the pending accredited M.A. in Buddhist Studies _________

Please indicate if you are interested in the Teacher’s Diploma ______________________________

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.) _____________________________________________________

_______________________________________________________________________________

________________________________________________________________________________

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_______________________________________

You must also complete and submit the Emergency Information Sheet (see last page).

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

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

___________________________________________________________________________________

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 ________________________________________________________

Doctor's name ________________________________________________________

Doctor's telephone ___________________________________________________

Are you covered by health insurance?____ 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 ________________

Residency Requirements

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