Application Form - Meditation Retreat By Venerable Ajahn Vajiro at UBV ( Fri, 3 Jan 2020 to Sun, 5 Jan 2020)
BANDAR UTAMA BUDDHIST SOCIETY(Reg No. 364)
A Dhamma inspired community in the heart of Petaling Jaya
3 Jalan BU 3/1 Bandar Utama 47800 Petaling Jaya.
Tel No. : 03-77106010/6013 Fax No. : 03-77106012
Web page: http://
www.bubs.my
Email: office@bubs.my
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Personal Details
Name
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Your answer
I/C No
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Please put in this format (XXXXXX-XX-XXXX)
Your answer
Age
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Your answer
Gender
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Male
Female
Address
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Your answer
Marital Status
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Single
Married
Telephone Number (House)
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Your answer
Telephone Number (Office)
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Telephone Number (Mobile)
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Your answer
Email
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Your answer
Religion
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Member of BUBS
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Yes
No
In case of emergency, the next of kin to contact:
Name
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Address
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Your answer
Relationship
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Your answer
Telephone number (House)
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Your answer
Telephone number (Office)
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Telephone number (Mobile)
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Your answer
Religious Organisation (associated with)
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Meditiation Experience
Yes
No
Type of Meditation
Your answer
Teacher's Name
Your answer
Length of longest retreat
Your answer
Duration per practice
Sitting
Your answer
Walking
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Purpose of joining the retreat
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Your answer
A) Please answer honestly whether you have mental disorder such as panic attack, anxiety, schizophrenia or manic depression
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Yes
No
If yes, please state nature and duration and whether it has been completely cured
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B) Any members of your family or next of kin who has or had mental illness?
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Yes
No
How are you related
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C) Any contagious diseases like TB or advanced diabetic that require constant treatment?
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Yes
No
D) Any health complications, restrictions, physical/psychological disorder that may or will affect you during your retreat?
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Yes
No
If yes, please give details.
Your answer
Preferred accomodation
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Air conditioned
Non-air conditioned
I hereby declare that the above information is true I am willing to abide by the meditation instructor’s advice and the Society regulations; otherwise I will leave on my own accord. I also understand that the organisers and the meditation instructor shall not be held responsible for any physical or mental injury incurred during or after attending this Retreat.
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Yes, I acknowledge above statement.
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