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Pa-Auk Latvia International Meditation Centre
Meditation Retreat from 1st of July - 21st of July 2018

Retreat Application Form

We respectfully request that you answer all questions completely and honestly

Email address *
Which part of the retreat would you like to attend? *
Personal Information
First Name *
Your answer
Family Name *
Your answer
Address *
Your answer
Phone number *
Your answer
Gender
Age
Your answer
Nationality
Your answer
Occupation
Your answer
Meditation Information
Please state type of meditation method used
Your answer
For how long have you used this method?
Your answer
Who is your current meditation teacher, if any?
Your answer
Medical Health Details
Please state medical conditions (if any) for example, high blood pressure, kidney / heart problems, asthma, diabetics, etc.
Your answer
Do you have, or have you ever had, any mental health problems such as significant depression or anxiety, panic attacks, manic depression, schizophrenia, etc.?If yes, please give details (dates, symptoms, duration, hospitalisation, treatment, present condition).
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).
Contact person in case of emergency
Name
Your answer
Relationship
Your answer
Address
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Email
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Phone
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