At which center is the course for which you are applying being conducted? Please Select A Center California (North Fork), USA Massachusetts, USA Igatpuri, Maharashtra, India Texas, USA Washington, USA British Columbia, Canada Belgium California (Southern), USA United Kingdom New South Wales, Australia Queensland, Australia Victoria, Australia Subiaco, WA, Australia Hobart, TAS, Australia Adelaide, SA, Australia New Zealand Dharmsala, H.P., India Jaipur, Rajasthan, India Japan Italy Prachinburi (near Bangkok), Thailand Phitsanulok, Thailand Yangon, Myanmar Spain Java, Indonesia Sri Lanka South African Center Illinois, USA Brazil Mexico Please note that only the centers on this list currently accept e-mail course registration applications. If the course for which you are applying is being held at a location other than one of those listed, you cannot use this e-mail application form and must submit your application by fax or post.
When does the course take place?
What type of course is it? (10-day, etc.) Course Type:
To apply for a place on the course, please complete this form, "sign" it below, and press the Submit button to e-mail it to the appropriate center, and await confirmation. You must answer all applicable questions fully. All information will be kept strictly confidental. If you are unable to submit this on-line application form, or the ASCII text file version appended hereto, please contact the applicable Center by phone, fax or e-mail and request an application form by mail. You may also download and print an application form in Acrobat PDF format and obtain more information about Acrobat from Adobe. If you are not contacted by the Center to which you are applying within a week or so, please contact it by phone or fax to ensure that your e-mail application form was received.
The application form for children's courses is only available in Adobe Acrobat PDF format.
Please note that, while the data sent via this application form is encrypted, information sent over the Internet is, in general, not totally secure and is potentially subject to interception by others during transmission. If you are concerned about the possibility of security risks of your confidental information while it is on the Internet, DO NOT USE THIS FORM. Submit your application by fax or surface mail. The information you provide on this form will be treated confidentially. Some of the information will be processed on computer. By completing and signing this form, you give your consent to the storage and use of this information by the Vipassana course organisers as described in the Privacy Policy applicable where the course for which you are applying is being held, a copy of which may be obtained from the course registrar or at the course site upon your arrival.
Please also note that if you do use this e-mail application form, you must still provide full, complete and detailed answers to ALL QUESTIONS in order for your application to be considered. Please do not fail to give an honest and complete answer in each blank space.
1. Are you driving and willing to be contacted by other students seeking a ride to the course? NoYes
2. Will a friend or family member be taking this course as well? NoYes If yes, please give details:
Name(s)/Relationship:
4. Have you completed a 10-day course with S.N. Goenka or any of his assistant teachers? No (New Student)Yes (Old Student)
b. Do you teach or practice on others? NoYes If yes, please give details.
2. How did you learn about Vipassana, or who introduced you to this course?
First Course: Date: Location: Teacher(s):
Most recent full course (Sat): 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? NoYes a. If yes, please give details.
2. Have you maintained your practice of Vipassana meditation since your last course? NoYes Please give details (how much time, daily, etc.).
3. Would you be willing to come early to help with set-up if needed? NoYes
4. Would you be willing to serve this course should the need arise? NoYes
5. If you are not attending the entire course, please give your arrival date and hour: and departure date and hour:
Do you have any physical health problems, medical conditions or diseases? NoYes 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.? NoYes 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? NoYes 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)? NoYes 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.
I further acknowledge and agree that any and all information provided in this application for acceptance into a Vipassana Meditation course, or otherwise provided by me to the vipassana organizations, may be used by the vipassana organizations for their purposes consistent with their privacy policies, as amended from time to time, a copy of which can be obtained as described above. Our online and general overall privacy polices are currently available at http://www.dhamma.org/privacy.htm; however, a hard copy of such policies is available upon request to us at: webmaster@dhamma.org.
Press the Submit button below to automatically e-mail this application form to the Center you have selected above. If you are not contacted by the Center to which you are applying within two weeks or so, please contact it to ensure that your e-mail application was received.
If you are unable to use this on-line E-mail application form, or the ASCII text version appended hereto, please contact the applicable Center by phone, fax or E-Mail and request an application form by mail.
