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I
am driving and willing to be contacted by other students seeking a ride to the
course. YES; NO.
Will a friend or family member be taking
this course as well? YES; NO. If yes, please state
Name/Relationship:
Do You
understand English very well? YES; NO; If no, please explain (extent
of English, native language, other languages).
Have you previously
completed a 10-day course with S.N. Goenka or any of his authorized assistant
teachers?
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NEW STUDENTS:
Please give
following details:
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? Who introduced you?
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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 last two years, any
prescribed medication? NO; YES.
If yes, please give details (dates,
types, dosage, present use).
Are you now taking, or have you
taken within the last two years, any alcohol or drugs (such as, marijuana,
amphetamines, barbituates, cocaine, heroin, or other intoxicants)? NO;
YES.
If yes, please give details (dates, types, amounts, addictions,
treatment, present use).
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