Membership

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Alternate Phone Number *

Email *

Have you previously received Precepts? *

Yes No

If yes, where and when did you receive precepts? *

Dharma Name *

Number of Precepts received: *

Briefly share any information about your practice that you believe to be relevant: *

Please select a membership level *

I will contribute *

Monthly Annually

How will you arrange payment of your contribution?

Choose one of the following: *

I will set up automatic payments from my bank I will provide a check (send to Lotus Heart Zen, 218 Allen Park Place, Oneida, NY 13421) I will submit my payment using paypal (see below) I would like to discuss a reduced membership rate and/or volunteering in lieu of regular contributions

For Family Membership level, please list the names of those who will be part of the membership: *

Monthly Sangha Membership Rate: $40

Yearly Sangha Membership Rate: $440

Monthly Student/Senior Membership Rate: $10

Yearly Student/Senior Monthly Membership Rate: $110

Monthly Patron Membership Rate: $80

Yearly Patron Membership Rate: $800

Lotus Heart Zen Meditation and Study Group Membership Form

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Location

Lotus Heart Zen Location

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