Vipassana Meditation Course 


COURSE APPLICATION 

From:              To: 

To apply for a place in the course, please complete this form, return it to the above address, and await notification. 
Please answer all questions fully. This information will be kept strictly confidential.

Name: First  
Last: 				Phone:Home
Work:
Street Address/P.O. Box Age: Gender: M o F • 
Date of Birth: Yr _______/Mo ______/Day ______ 
City State/Province Zip/Postal Code Country Occupation 
E-mail Address:

 1. Check here if you are driving and willing to be contacted by other students seeking a ride to the course: o 
2. Will a friend or family member be taking this course as well? No o Yes o If yes, 
Name(s)/Relationship:_____________________________________________________________________________ 
3. Native country: _______________ 
Native language: ______________ 
Other languages that you understand well:_____________________________________________________________ 
4. Have you completed a 10-day course with S.N. Goenka or any of his assistant teachers? Noo(New Student) Yeso(Old Student) 
New Students: 

1. Have you had any previous experience with meditation techniques, therapies or healing practices? Noo Yes• 
a. If yes, please give details. 
b.Do you teach or practice on others? No o Yes o If yes, please give details. 
2. How did you learn about Vipassana, or who introduced you to this course? 
Old Students: Date Location Teacher(s) 
First Course 
Most Recent Full Course(Sat) 
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? Noo Yes• 
a. If yes, please give details. 
b. Do you teach or practice on others? No o Yes o If yes, please give details. 
2. Have you maintained your practice of Vipassana meditation since your last course? No o Yes • 
Please give details (how much time daily, etc.). 
3. 
Check here if you can come early to help set-up if needed. • 
4. 
Check here if you would be willing to serve this course should the need arise. • 
5. 
If you are not attending the entire course, please give your arrival date and hour: 
and departure date and hour: 

(Continued on other side) 

appsit.doc0503 


New and Old Students: 

Do you have any physical health problems, medical conditions or diseases? No o 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 o Yes • 
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 alcohol or drugs (such as marijuana, 
amphetamines, barbiturates, cocaine, heroin, or other intoxicants)? No o Yes • 
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? No o Yes • 
If yes, please give details (dates, types, dosage, present use). 

I acknowledge that I have carefully read and understood the booklet Vipassana Meditation, Introduction to theTechnique 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 herebycertify that the above information is true to the best of my knowledge. 

Signature Date