Application Form - Meditation Retreat with Tan Ajahn Kalyano - 18-23 Dec 2018
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
I/C No/Passport No. *
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Age *
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Gender *
Address *
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Marital Status *
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Telephone Number (Mobile) *
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Religion
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Member of BUBS *
In case of emergency, the next of kin to contact:
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Address *
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Relationship *
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Telephone number (House) *
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Telephone number (Office)
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Telephone number (Mobile) *
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Religious Organisation (associated with)
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Meditiation Experience *
Type of Meditation *
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Teacher's Name *
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Length of longest retreat
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Duration per practice
Sitting
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Walking
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Purpose of joining the retreat *
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A) Please answer honestly whether you have mental disorder such as panic attack, anxiety, schizophrenia or manic depression *
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? *
How are you related
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C) Any contagious diseases like TB or advanced diabetic that require constant treatment? *
D) Any health complications, restrictions, physical/psychological disorder that may or will affect you during your retreat? *
If yes, please give details.
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Preferred accomodation *
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. *
** Personal Data Protection Act 2010 By signing this form, you consent to us processing and using your personal data in the manner as permitted by law and as stated in our Privacy Policy. An on-line copy of our latest Privacy Policy is located at https://bubs.my/privacy-policy
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