AJAHN MARTIN MEDITATION RETREAT 2018
Date: 1ST - 6TH MAY 2018
Venue: Bodhi Park ,Shah Alam
1A, Persiaran Serai Wangi, Seksyen U12, 40170 Shah Alam ,Selangor , Malaysia

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PERSONAL PARTICULAR
Name: *
NRIC Number: *
Please do not include the hyphen sign (-)
Birthday *
MM
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YYYY
Gender: *
Address: *
Mobile Number: *
Email: *
NEXT OF KIN TO BE CONTACTED IN CASE OF EMERGENCY
Name: *
Relationship: *
Mobile Number: *
MEDICAL HISTORY
Do you have any health, physical or emotional problems? *
Are you currently taking/on any form of medication (prescribed or otherwise)?   *
If your answer is yes for the above, please specify
During the retreat, I would like to observe *
Meditation Background
State on if you attended any Meditation classes or Meditation Retreat? *
Duration of Retreat Attended *
Method of Meditation and Meditation Teachers Name *
(e.g. Method - Teachers Name) * Note: Press enter for next line
ACKNOWLEDGEMENT
I hereby declare that all the above information provided is correct. I agree to abide by the instructions of our teacher Ajahn Martin and the rules & regulations set by the organising committee, otherwise I will be asked to leave. I understand that the organizer will not be responsible for any physical injuries sustained during the retreat. I also understand that the organizers reserve the right to amend any rules and regulations which they deem fit and necessary for the smooth running of the retreat. *
Required
CLOSING DATE : 15TH APRIL 2018
REMARKS:
The retreat is free of charged and will be supported by sponsors and donations. You are encouraged to make donations to support the cost of the retreat. Donations of any amount is welcomed.

All sponsors  or donations shall be payable to :
Ti-Ratana Community Center Penchala
CIMB Bank – 8001450727

Bank in slip can be send though channel below:
1.) E-mail to tiratanapenchala@gmail.com
2.) Text or whatsapp the picture of the transfer slip to Sis Yuh Ming (+60122313341) or Sis ST (+60123313171)

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