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Meditation Retreat with Ajahn Jumnien
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17 - 20 June 2012
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Venue - Strawberry Park Resort Cameron Highlands
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A) PERSONAL PARTICULARS
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Name :Age
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NRICGender:Male / Female *
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Address
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PostcodeCity/Town
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Telephone: HomeMobile Phone No.
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Email address:
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Religious organisation associated with :
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Please provide your room sharing partner's name (with same gender only):
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(If you do not have any, we will allocate for you).If you are alone & require single occupancy, it will be subject to addtional charge.
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Otherwise we will allocate you on triple room occupancy.
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B) NEXT OF KIN TO BE CONTACTED IN CASE OF EMERGENCY
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Name :Relationship:
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Telephone : HomeMobile Phone No.
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Address:
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D) MEDICAL HISTORY:
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Please specify if you have any health, physical
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or psychiatric problem
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I, _________________________________, the undersigned hereby declare that the above information is true and I am willing to abide by the organiser/Meditation Instructor’s advice and the Retreat’s rules and regulations, otherwise I will leave the retreat as instructed by the organiser/Meditation Instructor. I hereby agree and accept that neither the organiser nor the management of Wat Chetawan shall be held liable in the event of any injury (mental or physical), losses or damages occurred during this retreat.
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I enclose herewith:
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Meditation Retreat Fee (base on Twin sharing)RM500.00
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Donations (Optional)RM
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TOTAL500.00
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* delete whichever is not applicableSignature:
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Please make cheque payable toTi-Ratana Community Centre Penchala and mail to:
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21, Jalan Penchala , 46000 PJ, Selangor
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Alternatively, email completed form to trccpenchala@gmail.com and make direct payment to
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CIMB Bank ccount 1466 0000 259 057. Fax or email us the transaction slip once payment is made
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Closing Date : 01 June 2012