Vipassana Meditation
As taught by S.N. Goenka
in the tradition of Sayagyi U Ba Khin

COURSE APPLICATION FORM
To apply for a place in the course, please complete the form, send to the above address and await notification. Please answer allquestions fully. This information will be kept strictly confidential.
Course Dates:

From

First Name (Given Name)To
Last Name (Family Name)

Age (Years):

Gender:Male

Address/P.O. Box:Country:

Phone:
Home:Work:
Mobile/Cell:
Email:

FemaleDate of Birth:
Yr_______ Mo_______ Day_______
Occupation:

1.

Check here if you are driving and willing to be contacted by other students seeking a ride to the course.

2.

Will a friend or family member be taking this course as well?

No  Yes 

If yes, write Name(s) and Relationship.
3.

Native Country Native Language
Other languages you understand well4.

Have you completed any 10-day course with S.N. Goenka or any of his assistant teachers?

Yes (Old Student) No (New Student) For New Students
1.

Have you had any previous experience with meditation techniques, therapies or healing practices?

No  Yes a. If yes, please give details.
No  Yes b. Do you teach or practice these techniques/therapies on others?
If yes, please give details.
2.

How did you learn about Vipassana, or who introduced you to this course?

For Old Students
1.

First Course: Date __________________ Location _____________________ Teacher(s)2.

Most Recent Course (Sat): Date ______________ Location ________________ Teacher(s)3.

Total Number of 10-Day Courses: _____________ Sat full time ______________ Served full timea. Other courses Sat (Specify):b. Other courses Served (Specify):

4.

Have you practiced any other meditation techniques (including other types of Vipassana), therapies or healing
techniques since your last course with S.N. Goenka or his assistant teachers?
No  Yes a. If yes, please give details.
b. Do you teach or practice these techniques / therapies on others? No  Yes Vipassana Meditation Course Application Form - Page 1 of 2If yes, please give details.

For information on Vipassana: http://www.dhamma.org

5.

Have you maintained your practice of Vipassana meditation since your last course?

No  Yes 

If yes, please give details (how much time daily, etc.).
6.

Check here if you can come early to help set-up if needed.

7.

Check here if you would be willing to serve this course should the need arise.

8.

If you are not attending the entire course, please give your arrival / departure dates and times.
Arrival date and time ___________________________ Departure date and time

For All Students (New and old students)
1.

Do you have any physical health problems, medical conditions or diseases? If yes, please give details(dates, symptoms, duration, treatment, and present condition).

No  Yes 

2.

For women applicants: Please indicate whether you are pregnant.

No  Yes 

3.

Do you have, or have you ever had, any mental health problems such as significant depression oranxiety, panic attacks, manic depression, schizophrenia, etc.? If yes, please give details (dates,symptoms, duration, hospitalization, treatment, and present condition).

No  Yes 

4.

Are you now taking, or have you taken within the past two years, any alcohol or drugs (such asmarijuana, amphetamines, barbiturates, cocaine, heroin, or other intoxicants)? If yes, please givedetails (dates, types, amounts, additions, treatment, and present use).

No  Yes 

5.

Are you now taking, or have you taken within the past two years, any prescribed medication? If yes,
please give details (dates, types, dosage, and present use).

No  Yes 

6.

Any other information you wish to add.

I acknowledge that I have carefully read and understood the booklet Vipassana Meditation, Introduction to the Technique andCode of Discipline for Meditation Courses. I agree to stay on the course site and to abide by all the rules and regulations for theduration of the course. I realize that a Vipassana meditation course is a serious undertaking that will require my full mental andphysical health and I affirm that I am fit to participate in it. I hereby certify that the above information is true to the best of myknowledge.
In addition, I hereby consent to the storage and handling on a computer or otherwise of my above stated personally identifiable
information in accordance with the Privacy Policy of the facility at which the course for which I am applying is being held. A
copy will be provided on request to that facility.
Signature
Vipassana Meditation Course Application Form - Page 2 of 2DateFor information on Vipassana: http://www.dhamma.org