Contact Information

Have you completed a 10-day course with S.N.Goenka or any of his assistant teachers? : *

Yes

No

Select Yes if you are an old student in this tradition

Select Gender: *

Male

Female

Given Name: *

Last/Family Name: *

Age: *

Date of birth: *

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YYYY-MM-DD

Address: *

Street Address/P.O. Box

City: *

State: *

Zip/Postal Code: *

Country: *

Primary Language: *

Native Language or language you are most comfortable with

Other languages or dialects that you understand well? :

Email Address:

Leave this field blank if you do not have an email address

Home Phone:

Mobile Phone: *

Work Phone:

Fax:

Vipassana Information

Please give details of your first 10-day course:

Date of course (month and year): *

Enter as yyyy/mm, for example 2009/12. If you do not know, please estimate.

Location of course: *

If you do not remember, please write 'unknown'

Teacher(s) Name:

If you do not remember, please write 'unknown'

Details of your most recent full-time course completed as a student:

Date of course (month and year): *

Enter as yyyy/mm, for example 2009/12. If you do not know, please estimate.

Location of course: *

If you do not remember, please write 'unknown'

Teacher(s) Name:

If you do not remember, please write 'unknown'

Total number of 10-day courses sat full-time: *

Include 10 day courses only. Satipatthana, TSC should be listed with other courses sat.

Total number of 10-day course served full-time: *

Include 10 day courses only. Satipatthana, TSC should be listed with other courses served.

Other courses sat: *

Specify details

Other courses served: *

Specify details

Miscellaneous Information

Education: *

Occupation: *

Company Name: *

Enter NA if not applicable

Department: *

Enter NA if not applicable

Designation: *

Enter NA if not applicable

Practice Information

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? : *

Yes

No

a. If yes, please give details.:

b. Do you teach or practice these techniques / therapies on others? : *

Yes

No

If yes, please give details.:

Have you maintained your practice of Vipassana meditation since your last course?: *

Yes

No

If yes, please give details (how much time, daily, etc.). :

Since your last course, have you maintained the five precepts? : *

Yes

No

If no, please give details:

Health Information

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

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 prescribed medication?: *

Yes

No

If yes, please give details (dates, types, dosage, present use). :

Are you now taking, or have you taken within the past two years, any alcohol or drugs (such as marijuana, amphetamines, barbituates, cocaine, heroin, or other intoxicants)? : *

Yes

No

If yes, please give details (dates, types, amounts, addictions, treatment, present use :

Math question: * 10 + 6 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

By submitting this application, I hereby acknowledge that I have carefully read and understood the Code of Conduct for Dhamma Servers for the Vipassana Meditation course for which I am applying to serve and I have completed at least one 10-Day Vipassana meditation course as taugt by S.N. Goenka in the tradition of Sayagyi U Ba Khin.

I hereby certify that the above information is true and correct to the best of my knowledge.