Please read “INTRODUCTION TO THE TECHNIQUE” thoroughly before applying for the course.
* Courses available for over 15 years only * if can't send this form please send via email to doitcmm@gmail.com
From: To: View Availabled Course
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) (required) Last Name (Family) :
Birth Date : Month Year :
Age: Years Gender: Male Female
Street Address/P.O. Box
City : State/Province : Zip/Postal Code : Country : Telephone Mobile : Home Phone : 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:
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?
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
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. yes
Check here if you would be willing to serve this course should the need arise. yes
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
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?
If yes, please give details (dates, types, dosage, present use).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.
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