COURSE APPLICATION

From: To:

To apply for a place in the course, please complete this form, return it to Wat Tam Doi Tone, and await notification.Please answer all questions fully. This information will be kept strictly confidential.

Name: First (Given) Last (Family)

Date of Birth: ---- day ---- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month ---- month ---- January February March April May June July August September October November December Year ---- year ---- 2539 2538 2537 2536 2535 2534 2533 2532 2531 2530 2529 2528 2527 2526 2525 2524 2523 2522 2521 2520 2519 2518 2517 2516 2515 2514 2513 2512 2511 2510 2509 2508 2507 2506 2505 2504 2503 2502 2501 2500 2499 2498 2497 2496 2495 2494 2493 2492 2491 2490 2489 2488 2487 2486 2485 2484 2483 2482 2481 2480

Age: Years Gender: Male Female

Street Address/P.O. Box


City

State/Province

Zip/Postal Code

Country

Telephone Mobile Home

Occupation

E-mail

Check here if you are driving and willing to be contacted by other students seeking a ride to the course
Will a friend or family member be taking this course as well? Yes No

Name(s) / Relationship:


Native country: Native language:

Other languages that you understand well:

New Students:

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

Yes
No

If yes, please give details.


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

Old Students:

First Course

Date Location Teacher(s)

Most Recent Full Course

Date Location Teacher(s)

Total Number of 7-Day Courses: Full-time Served Full-time

Other Courses (specify):

Other Courses Served (specify):

Have you practiced any other meditation techniques (including other types of Vipassana), therapies or healing techniques?

Yes
No

If yes, please give details.


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

Yes
No

Please give details (how much time daily, etc.).


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

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

If you are not attending the entire course, please give your arrival date and hour: and departure date and hour:

New and Old Students:

Do you have any physical health problems, medical conditions or diseases?

Yes
No

If yes, please give details (dates, symptoms, duration, treatment, present condition).

Do you have, or have you ever had, any mental health problems such as significant depression or anxiety, panic attacks, manic depression, schizophrenia, etc.?

Yes
No

If yes, please give details (dates, symptoms, duration, treatment, present condition).

Are you now taking, or have you taken within the past two years, any alcohol or drugs (such as marijuana, amphetamines, barbiturates, cocaine, heroin, or other intoxicants)?

Yes
No

If yes, please give details (dates, types, amounts, additions, treatment, present use.)

Are you now taking, or have you taken within the past two years, any prescribed medication?

Yes
No

If yes, please give details (dates, types, dosage, present use).

I acknowledge that I have carefully read and understood the booklet Vipassana Meditation, Introduction to the Technique and Code of Discipline for Meditation Courses. I agree to stay on the course site and to abide by all therules and regulations for the duration of the course. I realize that a Vipassana meditation course is a seriousundertaking that will require my full mental and physical 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 my knowledge.

Signature

date month year