ASCII TEXT APPLICATION FORM FOR MEDITATION COURSE


Please answer all questions fully. All information
will be kept strictly confidential.


Dhamma Ketana Vipassana Meditation Centre 
P.O. Box 2, Cheriyanad P.O. , Chengannur, Kerala – 689511,  India
Phone: (0091) – 479 - 2351616    
Email: info@ketana.dhamma.org      
Website: www.ketana.dhamma.org


COURSE DATES: (from)__________(to)__________;

TYPE OF COURSE (10 DAY, ETC.):________________________;

FIRST NAME:______________________________________;

LAST NAME:______________________________________;


ADDRESS __________________________;

	____________________________;

	__________________;

	________________;

E-MAIL ADDRESS:____________________________;

TELEPHONE NUMBERS: (Work) (_____)___________;
		         (Home) (_____)___________;
		    
AGE: _____;

YEAR OF BIRTH: ________________;

MONTH OF BIRTH: ________________;

DAY OF BIRTH: ________________;

SEX:_____;

OCCUPATION:________________________________;

I am driving and willing to be contacted by other students seeking a ride to the course.  YES____;  NO____.


Will a friend or family member be taking this course as well? YES____;  NO____.

If yes, please state Name/Relationship: ______________________________________; 


Do You understand English very well?  YES____;  NO____;  If no, please explain (extent of English, native language, other languages).

Have you previously completed a 10-day course with S.N. Goenka or any of
his authorized assistant teachers?  NO____ (New Student);  YES____ (Old Student);

NEW STUDENTS:

1) Have you had any previous experience with meditation techniques, therapies, or healing practices? NO____; YES____.
   a) If yes, please give details:

   b) Do you teach or practice on others? NO____; YES____. If yes please give details:


2) How did you learn about Vipassana, or who introduced you to this course?

	___Book/Magazine (which one? _______________);

	___News Article (which paper? ______________);

	___Poster (where? _____________);

	___Internet (which site? ______________);

	___Friend/Word of Mouth (name?______________);

	___Other (What? _________________);

	___Who introduced you? (_________________________).


OLD STUDENTS:

Please give following details:

FIRST COURSE INFORMATION:

DATE:_________________________;

LOCATION:_____________________;

TEACHER(S):___________________;

MOST RECENT COURSE INFORMATION:

DATE:_________________________;

LOCATION:_____________________;

TEACHER(S):___________________;

TOTAL NUMBER OF 10-DAY COURSES:

Sat Full Time: ____;

Served Full Time: ____;

Other courses sat (specify)_______________________;

Other courses served (specify)_____________________;

1) Have you practiced any other meditation techniques (including
other types of Vipassana), therapies or healing techniques since your last course with S.N.
Goenka or his assistant teachers?  NO____; YES____; 
   a) If yes, please give details:

   b) Do you teach or practice on others? NO____; YES____; If yes please give details:


2) Have you maintained your practice of Vipassana Meditation 
since your last course? NO____; YES____; Please give details:


3) Would you be willing to come early to help with set-up if needed?  NO____; YES____.


4) Would you be willing to serve this course should the need arise?  NO____; YES____.


5) If you are not attending the entire course, please give your arrival date and hour: __________________;
							and departure date and hour:   __________________.	 

NEW AND OLD STUDENTS:

Do you have any physical health problems, medical conditions or diseases?  NO____; YES____.
If yes, please give details (dates, symptoms, duration, treatment, present condition).



Do you have or have you ever had any mental health problems such as, significant depression or
anxiety, panic attacks, manic depression, schizophrenia, etc.?
NO____; YES____.  If yes, please give details (dates, symptoms, duration, hospitalization, treatment, present condition).



Are you now taking, or have you taken within the last two years, any prescribed
medication? NO____; YES____. If yes, please give details (dates, types, dosage, present use).



Are you now taking, or have you taken within the last two years, any alcohol or drugs (such as,
marijuana, amphetamines, barbituates, cocaine, heroin, or other intoxicants)?
NO____; YES____. If yes, please give details (dates, types, amounts, addictions, treatment, present use).


  
I hereby acknowledge that I have carefully read and understood the Code of Discipline for the 
Vipassana Meditation course for which I am applying.  I agree to stay on the course
site and to abide by all the rules and regulations for the duration of the course.
I realize that a Vipassana Meditation course is a serious undertaking that will require
my full mental and physical health and I affirm that I am fit to participate in it.  I hereby
certify that the above information is true and correct to the best of my knowledge.

NAME: __________________________;

DATE: __________________________;