APPLICATION FORM
VIPASSANA MEDITATION CENTER WAT PHRADHATU SRI CHOMTONG VORAVIHARA

Please fill in the form to attend the course
Name and Last name *
Current Address *
E-mail *
Telephone *
Date of Birth: *
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Nationality: *
Intended length of stay at the Meditation Center: *
Date of Arrival (in Center): *
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Date of Departure (from Center) *
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DD
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Education and Profession *
Please list your previous meditation experience (Location - Teacher - Date (including how many days) *
Why do you wish to learn Vipassana Meditation at this time? *
Physical Health
Do you have or have you ever had any of the following: *
Required
If YES, please explain:
Are you currently taking any medication for a physical health issue? *
If YES, please explain:
Mental Health
Do you have any family history of mental health issues? *
If YES, please explain:
Have you ever been diagnosed with or are you currently being treated for any of the following: *
Required
If any of the above, please explain:
Have you ever been or are you currently addicted to any of the following: *
Required
If any of the above, please explain:
I hereby CERTIFY that above is true and correct and agree to faithfully abide by the teacher's instructions *
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