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To apply for a place on the course, please complete this form,
and "sign it as your name" and then send it and await confirm!ation.
Please answer all questions fully.
All information will be kept strictly
confidential
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COURSE LOCATION :
Purunnuri (In Kyongbook, Ipsuck-ri whabook-myon Sanju-city. Tel. 054-536-9820)
COURSE
DATES :
TYPE OF COURSE :
FIRST
NAME :
LAST
NAME :
ADDRESS :
E-MAIL
ADDRESS :
TELEPHONE NUMBERS;
(Cellular):
(Work) :
(Home) :
(Fax)
:
DATE OF BIRTH :
, AGE:
SEX : male , female
OCCUPATION :
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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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OLD STUDENTS:
Please give
following details:
FIRST COURSE
INFORMATION:
DATE :
LOCATION :
TEACHER(S) :
MOST
RECENT COURSE
INFORMATION:
DATE :
LOCATION :
TEACHER(S) :
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:
3) Would you be willing to come early to help with set-up if
needed?
NO; YES.
4) Would you be willing to serve this
course should the need arise?
NO; YES.
5) If you are not
attending the entire course,
please give your arrival date and hour:
and departure date and hour :
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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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By completing the spaces set forth below
with my name and the date,
I hereby acknowledge that I have carefully read
and understood
the Code of Discipline for the Vipassana Meditation course
for which I am applying.
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 and correct to the
best of my knowledge.
NAME:
DATE:
;
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Applification dor 10 day course |