Application Form
(Please complete this form form also available in rtf format and send to the contact address of the course you wish to attend, to receive the confirmation of your place on the course . Kindly arrive only on the day the course commences.)
I hereby declare that I have read and studied the code of discipline for the meditation course and accept the seriousness of the rules and regulations. I wish to join the course starting from: .......................... to ......................... If accepted, I promise faithfully to stay for the complete ten days and abide by all the rules.
Date :____________________ Signature:________________________
Male/Female: ______________________________________Age: ______
Full Name:___________________________________________________
Contact Address:______________________________________________
____________________________________________________________
Tel:__________________________ Pincode:_______________________
Education:_____________________________________________
Occupation: Business _______Service ______Student _______
Do you have any physical health problem? __________________
Have you ever had any mental health problem? ____________________
Are you taking any medication? __________________________________
Are you practising / have been practising any other form of meditation
technique? __________________________________________________
Are you practising any form of energy-based healing technique
(like Reiki etc)? ______________________________________________
(If Yes to any of the 5 above, please give full details on separate sheet of paper)
Mother Tongue / Native Language: _______________________________
Are you an old student: Yes____ No ____
(An old student is one who has done at least one full ten day course with Goenkaji or with one of his authorised assistants)
If an old student, when was your first course:________________________
Where: _______________________ With whom (A.T.): _______________
How many courses have you taken: _______________________________
10-day:____________ 20-day:_____________ 30/45-day: _____________
any other: ____________________________________________________
When was your last course: _____________________________________
Where: ______________________ With whom (A.T.): _________________
If you are a new student, who introduced you to Vipassana meditation?________________________________________________
(To be completed by an old student who has recommended a new applicant to the course)
Old Student’s Name:____________________________________________________
Address:_________________________________________________
____________________________________________________________
_____________________________________ Pin code: __________
I have clearly explained the rules and discipline to the applicant, and have stressed that he/she must stay for the full ten days and that he/she must strictly abide by all rules, regulations, timetable, noble silence etc.
I believe, the applicant has fully grasped the importance of them, before he/she signed the application form. Kindly confirm his/her admission to the course.
I have attended ____________ No. of courses and the last course was on_________________.
Date:___________________Signature:_______________________