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
 

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       :

 


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? 

 


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?
                               

 


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              :

 


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).
                            

 


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: ;

 

 

Applification dor 10 day course