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Meditation Session Registration & Consent Form
Please fill out this form sincerely. After submitting, print or save a copy of your responses and bring it to the meditation session.
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Email *
SECTION A: Personal Information
Please provide all the personal details requested and failure to do so would disqualify acceptance of your request for joining the meditation retreat
Full Name *
Date of Birth *
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Gender *
Occupation *
Email Address *
Contact number *
Family contact name & number (In case of emergency) *
City of Residence *
Full residential address *
SECTION B: Health Information
Please honestly and truthfully indicate all the details and disclose without any inhibitions or doubts. These details are collected in order to make sure that you are fit before you come here and are fit when you leave this place.
Do you currently suffer from any of the following? *
Required
If “Other”, please specify:
Have you ever been diagnosed with a psychological condition? (Yes/No) *
If yes, please describe briefly:
Are you currently on any medication (including psychiatric)? (Yes/No) *
If yes, please specify
If yes, please specify
Do you have any physical condition affecting sitting? (Yes/No) *
If yes, please specify
SECTION C: Meditation & Spiritual Background
Share your meditation and background from which you are coming from including the traditions you follow as in Zen, Goenka/U Ba Khin/Ajahn or Thai traditions/Sri Lankan/Hindu/Christian/Islam or any other traditions that you would like to share
Have you previously attended any meditation retreat/course? (Yes/No) *
If yes, which tradition(s)?
Teacher(s) or Center(s) you learned from:
What type of practice do you continue now, if any? *
Required
Are you able to watch the breath in mindfulness for the whole day? *
Required
Are you familiar with Buddhist texts or teachings? (Yes/No) *
If yes, which traditions you are aware of?
What are your expectations from this session? (Checkboxes) *
Required
If others, please specify
SECTION D: Conduct During the Session
In this section, you would have to agree to maintain self-discipline including the 5 or 8 precepts ensuring that you get all the benefit from meeting the Dhamma teacher. Also, one needs to maintain silence for the entire duration of the course to get maximum benefit
Precepts - Mandatory *
Required

I agree to observe noble silence during the session. (Yes/No)

 *

I understand that this is an internal practice, not a discussion forum. (Yes/No)

 *
I agree to follow the teacher’s instructions sincerely. (Yes/No) *

I will not practice any other method during the session. (Yes/No)

 *
Which date you would like to attend the course? *
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DD
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SECTION E: Declaration
Here you are going to declare on all that on what you have said is true to best of your knowledge. 
I confirm the above information is true and I am attending voluntarily and do not hold Anumodana Sankalpa Meditation Centre in any way responsible for my meditation working or not working  *
I understand this session is not a substitute for medical or psychiatric treatment. (Yes/No) *

Declaration and Waiver of Liability

Please read the following carefully before submitting:

I hereby declare that all the information provided by me in this form is true and complete to the best of my knowledge.

I fully understand and acknowledge that:

  • I am participating in this meditation session voluntarily.

  • I have disclosed all known physical and mental health conditions.

  • I accept full responsibility for any medical issues arising during or after the session, and I will bear all associated costs.

  • Anumodana Sankalpa Meditation Centre, its teachers, volunteers, or organizers cannot be held liable for any injury, illness, or unfortunate event, including hospitalization or death.

  • I understand that improper application or misunderstanding of meditation instructions may lead to unintended effects, for which the centre bears no responsibility.

By selecting "I Agree," I acknowledge that I have read, understood, and voluntarily accept all terms and conditions above.

Do you agree with the above Waiver and Liability clause? *
A copy of your responses will be emailed to the address you provided.
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