Vipassana Meditation Course

COURSE APPLICATION

From:___________________ To:___________________

To apply for a place in the course, please complete this form, return it to the above address, and await notification. Please answer all questions fully. This information will be kept strictly confidential.
Name: First (Given) Last (Family)
 
Phone:  Home  (            )
  Work  (            )
Street Address/P.O. Box
Age: Gender: M / F
Date of Birth: Yr_______/Mo______/Day______ 
City State/Province Zip/Postal Code Country
 
Occupation
E-mail Address:
1. Check here if you are driving and willing to be contacted by other students seeking a ride to the course: O
2. Will a friend or family member be taking this course as well? No / Yes  If yes,
    Name(s)/Relationship:______________________________________________________________________
3. Native country: _______________ Native language: ______________
    Other languages that you understand well: ____________________________________________________
4. Have you completed a 10-day course with S.N. Goenka or any of his assistant teachers? No (New Student) / Yes (Old Student)
New Students:
1. Have you had any previous experience with meditation techniques, therapies or healing practices? No / Yes
    a. If yes, please give details.
 
    b. Do you teach or practice on others? No / Yes If yes, please give details.
 
2. How did you learn about Vipassana, or who introduced you to this course?
Old Students:
  Date Location Teacher(s)
First Course _________ __________________ __________________
Most Recent Full Course(Sat) _________ __________________ __________________
Total Number of 10-Day Courses: Sat Full-time _________ Served Full-time _________
Other Courses Sat (specify):  _____________________________________________________
Other Courses Served (specify):  _____________________________________________________
1. 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 on others? No / Yes If yes, please give details.
 
2. Have you maintained your practice of Vipassana meditation since your last course? No / Yes
  Please give details (how much time daily, etc.).
 
3. Check here if you can come early to help set-up if needed. O
4. Check here if you would be willing to serve this course should the need arise. O
5. 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? No / Yes
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.? No / Yes
If yes, please give details (dates, symptoms, duration, hospitalization, 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)? No / Yes
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? No / Yes
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 the rules and regulations for the duration of the course. I realize that a Vipassana meditation course is a serious undertaking 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