Application for First Step Program: a 4-week live-in program at New Dvaraka,L.A.

[krsna]

The International Society for Krishna Consciousness

Founder Acarya A.C. Bhaktivedanta Swami Prabhupada

 

The First Step Program - Application

Form Revised 06/23/02

New Dvaraka Community – Los Angeles, Ca.

This is an application for the First Step Program, a four-week live-in program at

the New Dvaraka Community in Los Angeles, California designed to provide

immeasurable spiritual benefit to every sincere participant.

Thank you in advance for filling out this application as completely and honestly

as possible. We know that some of the questions on this application are intensely

personal. All of your strengths and challenges are likely to become apparent within a

pretty short time here. We don’t expect people to be perfect. We do expect everyone to be

respectful of themselves and others and humble to the degree that they can look at their

issues; and to some degree be able to move freely around their own “self-image”- their

ego, and their “world view” exploring a very real alternative. If you foresee potential

concerns with your application, please bring them up so we can talk about it and try to

work something out. We know everyone can benefit from even the slightest association

with devotees, Srila Prabhupada’s books, and darshan of our deities, Sri Sri Rukmini

Dvarakadisha— who you are, where you come from or what you have done in the past

may always be overcome!

Please include one recent Passport type photo with your application. (If you are

already here at the community we can snap a digital photo- just ask!) Also, remember to

attach any items noted with a * on the application. You may return this application to

the Bhakta/Bhaktin Program Leader; or if you are not living locally to:

The Program Director – First Step

International Society of Krishna Consciousness

3764 Watseka Avenue

Los Angeles, Ca. 90034 USA

Thank You for your interest in visiting New Dvaraka for a few weeks of spiritual bliss!

Please type or print your answers clearly.

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PERSONAL DETAILS

Today’s ____/ ____/ ____

Month Day Year

Your Current Legal Name: _______________ _________________ _______________

First Middle Last

Have you taken formal spiritual initiation (either within ISKCON or elsewhere) from

anyone in the past? Circle One: Yes No

If yes, by whom? _

Is this person affiliated with a particular group? Circle One: Yes No

If so, what is the name of that group? _____________________________When? _____

Year

Initiated Spiritual Name: _

Name you Prefer to be called by: __________

If you are female and married what is your Maiden Name?: _______________________

Have you ever gone by other names (aliases)? If so, please specify:

_________________________, ________________________, ____________________

Check One: Are you currently interested in exploring— a long-term, live-in

commitment to a spiritual community, an opportunity to retreat for some time develop

the spiritual side of your life and put the day-to-day world in better perspective, or

perhaps you are just curious about religious life?

Your Living Address: ____________ ________________________Apt.# ______

Number Street Name

City: _ State: ______ Zip: _______________

Country: ____________________________

Check One: Is this your Current? Or Last Address?

Your Mailing Address: ____________ ________________________Apt.# ______

Number Street Name

City: _ State: ______ Zip: _______________

Country: ____________________________

Check One: Is this your Current? Or Last Mailing Address?

E-mail address: ______________________@_

Your Phone Number(s)— Home (____) ____________ Work (____) ____________

Pager (____) _____________ Cell (____) _____________ Fax (____) _____________

E-mail ____________________ @ ______________________

Driver’s License Number: _________________________Issuing State: _____________

Class(Licensed to Drive School Bus, Heavy Trucks, etc): _________________________

Expiration ____/ ____/ ____

Month Day Year

Is this an International Driver’s License? Circle One: Yes No

Social Security Number: __________ - _____ - ____________

Circle One: Male Female Race: _______________ Weight: ___ Circle One: Lbs. Kg.

What you consider your family origin to be.

Height: ____/____ Circle One: Ft./In. Cm. Hair Color: _______ Eye Color: ________

Language (or Languages) you grew-up speaking: _______________________________

Ability to speak American English: Circle One: Excellent Good Fair Poor

Ability to write American English Circle One: Excellent Good Fair Poor

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Your Birth ____/ ____/ ____ Your Age Today: _______

Month Day Year Years

When did you last live at home? _________

Year

Please Note: If you are under 18 we must secure written permission from your

parent(s) or legal guardian before allowing you to stay with us.

Are you a U.S. Citizen? Circle One: Yes No

If you are not a U.S. Citizen please answer the following questions:

What is your Citizenship? ___________________________ What type of Visa do you

hold? Visitor Tourist Other __________________

Visa Expiration date? : ____/ ____/ ____ What is your Passport Number?____________

Month Day Year

* Please attach a copy of the page from your passport with your name and passport

number and also

* Please attach a copy of your USA Visa.

Do you have a “Green Card”? Circle One: Yes No

* If yes, please attach a copy with this application.

Marital status— Circle One: Never Married Single Common-Law Marriage

Married Separated Re-Married Divorced Widow/er

If you are currently Married— Date Married: ____/ ____/ ____

Month Day Year

If you are married or have a common-law marriage what is your- Current Spouse’s Legal

Name: _______________ _________________ ________________________________

First Middle Last

Do you have children? Circle One: Yes No If yes, how many? ____

What are their ages? ______ _______ _______ _______ _______ _______

If any of your children are not living with you, do you have any court ordered

responsibility to support this(these) child(ren)? Circle One: Yes No

Note: We rarely admit individuals to the First-Step Program who intend to bring

their children with them to the Community. Under unique circumstances and by

special arrangement, we may be able to make some accommodation for an

otherwise highly qualified married couple planning to attend together.

If you have children, will they be coming with you to New Dvaraka? Circle One: Yes No

Their Name(s) & Age(s)? ___________________ ____ / __________________ ____

Name Age in Years Name Age in Years

Personal Character Reference that we may contact— This may be a devotee you have

known for some time, or any personal friend:

Name: ____________________________ ___________________________

First Last

Address: ____________ _____ Apt.# ______

Number Street Name

City: _________________________________ State: ______ Zip: _________________

Country: ________________________

How long have you known this person? _________ __________

Years Months

References’ Phone Number(s)— Home (____) ___________ Work (____) ___________

Pager (____) _____________ Cell (____) _____________ Fax (____) _____________

E-mail ____________________ @ ______________________

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Does this person know you are applying for this First Step Program?Circle One:Yes No

When is the best time to reach them by phone? ________ ________ AM PM and at

Day Time

which number? Circle One: Home Work Pager Cell Fax E-mail

Legal Names- Father: _____________________ Mother: __________________

Ages of Parents- Father _______ Mother ______

Occupations of Parents- Father __________________ Mother _____________________

Brother’s- Name(s), Age(s) & Occupation(s)____________ _______ ________________

____________ _______ ________________

____________ _______ ________________

Sister’s- Name(s), Age(s) & Occupation(s)____________ _______ ________________

____________ _______ ________________

____________ _______ ________________

If any of your parent(s)/step-parent(s) were initiated within ISKCON please provide:

Their Initiated Names- Father: _____________________ Mother: __________________

If you are under 25 years of age, please provide at least one parent(s)’ contact

information:

Legal Name: ________________ _______________ ____________________________

First Middle Last

Relationship? Circle One: Father Mother Step-Father Step-Mother Guardian

Address: ____________ _____ Apt.# ______

Number Street Name

City: _________________________________ State: ______ Zip: _________________

Country: ___________________________

Parents’ Phone Number(s)— Home (____) ____________ Work (____) ____________

Pager (____) _____________ Cell (____) _____________ Fax (____) _____________

E-mail ____________________ @ ______________________

When is the best time to reach them by phone? ________ ________ AM PM and at

Day Time

which number? Circle One: Home Work Pager Cell Fax E-mail

Did you serve in the Military? Yes No

If so, What Branch? ___________ Date Entered _____/ ______/ ______

Date Discharged ______/ _______/ _______ Type of Discharge ____________________

Please attach a copy of your discharge papers.

Highest Rank Held ________________________

Valuable Experience or Training Received:

Do you own any possessions (houses, cars, or other “valuable” things?)

______________________

Have you ever received any awards? ______

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We understand that some young people, who have been visiting the Hare Krishna

temple for some time, have for this reason put a strain on the relationship with

their parents. If this is the case for you, look back to the time prior to this period,

as you answer the following question…

If you are under 25 years of age, please answer the following questions about your

relationships with your parents:

What is your current relationship like with each of your parents/step-parents?

Father-

Circle One: Excellent OK Fair Poor None Parent Deceased

How long ago did you last see him in person?

Circle One: In the last— Month Year More than a Year

Mother-

Circle One: Excellent OK Fair Poor None Parent-Deceased

How long ago did you last see her in-person?

Circle One: In the last— Month Year More than a Year

Step-Father-

Circle One: Excellent OK Fair Poor None Parent-Deceased

How long ago did you last see him in-person?

Circle One: In the last— Month Year More than a Year

Step-Mother-

Circle One: Excellent OK Fair Poor None Parent-Deceased

How long ago did you last see her in-person?

Circle One: In the last— Month Year More than a Year

Other Parent Figure or Guardian-

Circle One: Excellent OK Fair Poor None Deceased

How long ago did you last see them in-person?

Circle One: In the last— Month Year More than a Year

EMPLOYMENT DETAILS

Are you presently employed? Circle One: Yes No

At this time, do you have any independent means of financial support?

Circle all that apply:

Savings Welfare SSI A Job I will return to after my stay at the Temple

Self-Employment Trust Fund Workman’s Comp Unemployment Disability

Alimony Social Security Benefits-What type, from when and where

_Other _______________________________

Is this income sufficient to support the lifestyle you are accustomed to maintaining? If

you were to decide to remain permanently, and become a full-time member of our

Community, do you expect this income stream would continue? How long? ____ _____

Years Months

How many different jobs have you had in the past year? ______________

What was the longest you stayed at any of these jobs? ______________

Why did you leave? ____

If you are self-employed, please provide the following information:

Business Name: ______

Nature of this Business?__

How long in this business?____________

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Your Business Address: ____________ ________________________Apt.# ______

Number Street Name

City: _ State: ______ Zip: _______________

Country: _________________________

Business Number(s)— Home (____) ___________ Work (____) ___________ Pager

(____) _____________ Cell (____) _____________ Fax (____) _____________

Regarding your (Check One): current or most recent employment—

Please provide the following information:

Name of Company: ____

Your Highest Position There: ______________________________

Company Address: ____________ ________________________

Number Street Name

City: ___ State: ______ Zip: _____________

Country: ____________________________

Supervisor’s Name: ___________________ ________________

First Last

Supervisor’s Phone(s): Home (____) ___________ Work (____) ___________

Pager (____) _____________ Cell (____) _____________

May we speak discreetly to your supervisor? Circle One: Yes No

If yes, when is the best time to reach them by phone? _______ _______ AM PM and at

Day Time

which number? Circle One: Home Work Pager Cell Fax

How long have you been/were you, at this job? _______ _______

Months Years

If you are no longer employed, what was your last date of employment at this company?

____/ ____/ ____

Month Day Year

Why did you leave? ____

BACKGROUND INFORMATION

Have there been any recent notable changes in your life (behavior, friends, activities,

employment, personal realizations, etc.)?

7

Have you been convicted of any crime(s), misdemeanor (minor crime) or felony within

the last 5 years? Circle One: Yes No

If yes, please describe the charge, your sentence and your current status with these

conviction(s):

Have you ever been in prison? Circle One: Yes No If so, please explain, giving dates

and places.

Have you been cited for any moving traffic violations in the last 3 years?

Circle One: Yes No If yes, please describe the charge:

Regarding your Education: Please Check All that Apply- Did You?:

Earn a GED?

Graduate from High School?

Attend Some College

Earn an Undergraduate Degree If so, What College? __________________________

Degree ___ Field(s) of Study _________________________________Year? ___

Earn a Graduate Degree If so, What College? ________________________________

Degree ___ Field(s) of Study _________________________________Year? ___

Attend a Technical or Vocational School –Course of Study ______________ Year? __

Current Vocational/Technical Certificates ________________________________

* If so, Please attach a copy with this application.

Current Professional Licenses (Other than Driver’s License) _______________________

* If so, Please attach a copy with this application.

Do you have a recent (updated within the last year) resume? Circle One: Yes No

* If yes, please attach a copy with this application.

HEALTH

Are you celibate by choice at this time? Circle One: Yes No

How long? Circle One: Weeks Months Years

Why?

Have you ended a sexually active relationship within the last year? Circle One: Yes No

Do you consider yourself? Circle One: Homosexual Bisexual Transsexual “Straight”

Does your diet commonly include any of the following?

Please UNDERLINE all that your regularly eat, and

CIRCLE those that you feel you may have been overdoing in the last year:

Soft Drinks Refined Sugars White Flour Hard Cheese Milk Butter Ice Cream

Tofu Meat Whole-Grain-Foods Veggies Fresh Fruits Fish Beans Garlic

Onion Spicy Foods Fast-Food Canned Foods Restaurant Food Coffee

8

Regarding your daily eating habits, do you most commonly— (Check One or Two):

Cook for yourself Someone in your family cooks for you Dine-out Grab

snacks and fast-food when you can

Do you have any medically necessary dietary restrictions or necessities? If so, what are

they?

Do you regularly take non-prescription dietary supplements? If so, what and why?

Do you have any serious illnesses? Circle One: Yes No If so, please describe

______________________

Have you had or do you have any life threatening illness (cancer, AIDS, emphysema,

heart problems, asthma, epilepsy, etc.)? _____

Please list any other medical problems and what you are doing about them

______________________

Are you taking any prescription medication, or should you be taking any medications you

have chosen not to take. _

Have you ever involuntarily or voluntarily received treatment for mental or emotional

problems by a professional psychologist, psychiatrist or mental health center? Yes No

If so, please describe your current situation on a separate piece of paper.

Do you have any allergies you have to deal with regularly? ______________________

Do you have any hobbies you regularly enjoy? If so, what do you like to do?

Have others mentioned they feel you have may have a problem with substance abuse?

Circle One: Yes No

What are your three greatest needs in order of priority?

1)__________

2)__________

3)__________

What kinds of issues or challenges have you faced in your close relationships?

Do you have difficulty hearing? Circle One: Yes No

Have you found a solution for this problem?

Do you wear glasses? Circle One: Yes No

Do you have trouble seeing to read? Circle One: Yes No

Is it easy for you to express your feelings?

Check One: Most often-Yes Most Often-No Sometimes

9

Have you ever had hallucinations? Circle One: Yes No

Do you enjoy being with other people? Circle One: Yes No Sometimes

Do you sometimes hanker to be alone? Circle One: Yes No Sometimes

Do you have trouble sleeping? Circle One: Yes No If yes, why?

Have you ever had a desire, a plan and a means to commit suicide? Circle One: Yes No

Closest direct relative in case of a medical emergency?

Name: ____________________________ ___________________________

First Last

Address: ____________ _____ Apt.# ______

Number Street Name

City: ____ State: ______ Zip: ____________

Country: ___________________________

Years Months

Emergency Phone Number(s)— Home (____) ___________ Work (____) ___________

Pager (____) _____________ Cell (____) _____________ Fax (____) _____________

E-mail ____________________ @ ______________________

Did you regularly attend any sort of religious institution as a child? Circle One: Yes No

If yes, what denomination? ____

At the time, did you willingly accept the standard rites of passage for people attending

that institution? Circle One: Yes No Mostly

Have you stopped regularly attending any religious or spiritual functions? Circle One:

Yes No If yes, when? __________ And Why?

Year

10

We have found from long experience that individuals practically engaged in daily

activities according to their natural propensities and training, are more satisfied and

successful in their long-range pursuit of devotional service.

Using the following criteria, please indicate the level of work skills you have on the

following list:

P Indicates you have considerable Professional field experience in the skill

T Indicates you are Trained in the skill but have less than 2 years of full time

field experience practicing the skill

S Indicates you have Some regular paid work experience in the skill

N Indicates you have No work experience in the skill

L Indicates a skill you have thought you would like to Learn

__Carpentry __Plumbing __Electrical __Electronic __Masonry

__Grounds Maintenance-Tree/Shrub Care __General Mechanical Repair __Auto Repair

__Artistic Talent __Sewing __Painting __Sculpture

__Printing __Desktop Publishing __Typing __Telephone Skills

__Accounting/Bookkeeping __Clerical __Microsoft Office Applications

__Nursing Healing __Arts __Adult Counseling

__Conflict Resolution __Communicating __Facilitation __Problem Solving

__Coordination of Other’s Activities __Supervision

__Child Care __Elementary Teaching __Tutoring __Counseling Summer Camp

Restaurant Experience: __Cooking for Meals of 50+ __Baking __Serving

__Cleaning __Host(ess) __Cashiering __Prep Work __Pot Washing

__Photography __Video Production __Film Editing __Sound Engineering

__Fund Raising __Grant Development __Marketing __Telephone Skills __Publicity

__Story Telling __Listening __Dramatic Performance on Stage

__Electrical or Civil Engineering __Architecture __Drafting

__Singing __Playing Musical Instruments __Songwriting

__Certified Lifeguard __CPR

11

LIFESTYLE

When? ________, and How did you FIRST come into contact with the Hare Krishnas?

Year

Check One: Read one of our books At a school Hare Krishna program From a

friend or acquaintance Met a devotee or saw us chanting on the street At a yoga

studio Other

What was your first impression of this Hare Krishna lifestyle?

Accommodations are in dormitory-style housing. Do you snore? Circle One: Yes No

Many of the daily service activities you may be asked to perform while you are here are

physically and mentally demanding— sometimes require heavy lifting, bending, long

standing or sitting, and concentrating on oral lecture and written materials. As such, this

program is not appropriate or helpful to everyone, all the time. To properly arrange for

everyone to have the best opportunity to benefit from this program, please provide the

following health information:

Do you have any physical limitations that would make dormitory accommodations (or

stairs) a hardship for you?

Have you consumed alcoholic beverages in the past year? Circle One: Yes No

How often? Circle One: Daily Once a Week Less than Once a Month

How long since your last alcoholic drink? ________________

Are you or have you been in a treatment program, or do you regularly attend AA

meetings? Circle One: Yes No

Have you used non-prescription or illicit drugs for recreation in the past year?

Circle One: Yes No

What? _______________________ How often? Check One: Daily Once a Week

Less than Once a Month

What? _______________________ How often? Check One: Daily Once a Week

Less than Once a Month

Are you or have you been in a treatment program designed to eliminate this behavior?

Have you played the lottery or engaged in other forms of gambling in the past year?

Circle One: Yes No

Have you sought counseling for overindulgence in this behavior? Circle One: Yes No

If you have considered, or tried to follow our four regulated principles have you found

any hard to follow? Please Check Which:

No eating of meat, fish or eggs

No gambling

No use of intoxicants – including recreational drugs, alcohol, cigarettes, as well as

any drinks or foods containing caffeine

No sex (except for having children within marriage)

12

Have you or do you now practice Hatha Yoga? Circle One: Yes No

What recent changes (if any) have you had in your religious/spiritual life?

EXPERIENCE with ISKCON

Do you believe God, or a spiritual guide has sent you to the Hare Krishna Temple

specifically?

Have you been inside a Hare Krishna Temple? Circle One: Yes No

If so, in what location? _____________________________

Did you? Circle One: Visit Briefly Reside There

If you lived there— How Long? _______ _______

Months Years

Why did you leave?

What was the name of either your “authority” or the Temple President while you were

there? (Please do your best at trying to spell their name(s) even if you’re not sure how.) _______________

Have you ever been asked to leave an ISKCON Temple? If so, please help us understand

what happened?

Have you been chanting on (japa) beads prior to your visit to New Dvaraka?

Circle One: Yes No How often? __

IF you have taken initiation within ISKCON, or attempted to follow a vow of chanting

sixteen rounds of Hare Krishna japa daily, have you been successful? Have you been

able to establish some absolute minimum number you can complete daily? ___________

Number Daily

Have you read Bhagavad-gita? Circle One: Yes No

Whose translation- if you know? ___________

Have you performed some form of meditation in the past? Circle One: Yes No

What type? _________________________ How Often? __________________________

When? (Circle One): Recently Within the last Year Less than Ten Years Ago

Have you performed some type of voluntary devotional service (or seva) in the past?

Circle One: Yes No When? _______ Where? _______________________________

Year Name of Institution

What sort of daily activity(s) did you perform?

How long were you there?

Why did you leave?

13

What is motivating you to consider visiting/living in a spiritual community at this time?

.

14

AGREEMENT

I understand that all residents of the New Dvaraka Temple ashram where I will be

residing, including visitors, are expected to rise early and come to all the morning and

evening programs (unless specifically excused by one’s spiritual authority within the

Temple community). I will follow the four regulated principles of the International

Society for Krishna Consciousness—

1. No eating of meat, fish or eggs

2. No gambling

3. No use of intoxicants – including recreational drugs, alcohol, cigarettes, as

well as any drinks or foods containing caffeine

4. No sex (except for having children within marriage)

while I am in residence in the New Dvaraka Community. I understand that everyone who

lives in the Temple ashram is expected to perform thirty-five hours of service each week

in reciprocation for the benefits provided by the New Dvaraka Community. I understand

that appropriate accommodation may be possible for specific, bona fide medical

conditions with prior arrangement. I acknowledge that any false information or failure to

maintain the above mentioned standards may obligate the Temple administration to

withdraw my visitor privileges. Life within the shelter of the Temple ashram is meant for

spiritual development and the current residents have chosen to voluntarily accept these

austerities as a way to become isolated from the day-to-day anxieties of the world. I too

hope to take full advantage to this opportunity while I am here.

I understand that accommodations are in shared dormitory style ashram facilities

with attached baths. I will need to bring enough money for medical expenses, gifts and

other extras, and transportation home at the end of my stay.

All information provided on this application is correct and will be kept strictly

confidential— to be shared only with members of the Program evaluation committee. It is

hereby understood that the New Dvaraka Community can not and will not be held

responsible for any personal property left, lost or stolen while in the Program. I agree

that any property or money left at the New Dvaraka Community over thirty days from my

departure date, announced or unannounced, becomes the property of the New Dvaraka

Community. It is further understood that I release the New Dvaraka Community from all

financial responsibilities in case of accident, injury, illness, or other imponderable

misfortune.

Signed __ Date _____/ _____/ _____

 

[theist]

a bit much perhaps.

 

I am surprised they don't take a DNA sample.

[krsna]

How about a lie detector test ?

 

Or a a dozen character references ?