APPLICATION FORM
VIPASSANA MEDITATION CENTER WAT PHRADHATU SRI CHOMTONG VORAVIHARA
Please fill in the form to attend the course
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Name and Last name
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Your answer
Current Address
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Your answer
E-mail
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Your answer
Telephone
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Your answer
Date of Birth:
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DD
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YYYY
Nationality:
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Your answer
Intended length of stay at the Meditation Center:
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Your answer
Date of Arrival (in Center):
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MM
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DD
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YYYY
Date of Departure (from Center)
*
MM
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DD
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YYYY
Education and Profession
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Your answer
Please list your previous meditation experience (Location - Teacher - Date (including how many days)
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Your answer
Why do you wish to learn Vipassana Meditation at this time?
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Your answer
Physical Health
Do you have or have you ever had any of the following:
*
Major Disease
Major Surgery
Back Problem
None of the above
Other:
Required
If YES, please explain:
Your answer
Are you currently taking any medication for a physical health issue?
*
Yes
No
If YES, please explain:
Your answer
Mental Health
Do you have any family history of mental health issues?
*
Yes
No
If YES, please explain:
Your answer
Have you ever been diagnosed with or are you currently being treated for any of the following:
*
Depression
Panic/ Anxiety Attacks
Bi-Polar Disorder
Schizophrenia
Eating Disorder
ADHD
Autism
Obsessive Disorder
Suicidal Behavior
None of the above
Other:
Required
If any of the above, please explain:
Your answer
Have you ever been or are you currently addicted to any of the following:
*
Prescription Drugs
Other drugs
Alcohol
Electronic Devices
Video Games
Others
None of the above
Required
If any of the above, please explain:
Your answer
I hereby CERTIFY that above is true and correct and agree to faithfully abide by the teacher's instructions
*
Yes, I agree
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