Teacher Registration – Mitra Upakram

Course Date

Starting Date

Day

Month

Year

Ending Date

Day

Month

Year

Select

Teacher Information

Name *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Age

GenderMaleFemale

Mobile Number

Landline

Email Address

Photo ID Type

Photo ID Number

Education

Name of School

School Address

Designation

Will friend or family member be taking this course as well? IF yes, write Name(s) and Relationship.YesNo

EMERGENCY teacher NAME & NUMBER (Also mention the relationship to the person). *

Language Comprehension: How well do you understand the language(s) in which this course will be conducted?

English : NoneBasicIntermediateExpert

Hindi:NoneBasicIntermediate Expert

Languages you are fluent in

For Old Students (Details of courses done in the tradition of Sayaji U ba Khin as taught by S. N. Goenka)

Have you completed a 10-day course with S.N.Goenka or any of his assistant teachers?: YesNo

For All Students (New and Old Students)

Vipassana is a non-sectarian technique which aims for the total eradication of mental impurities and the resultant highest happiness of full liberation. Its purpose is never simply to cure diseases. But, in order to facilitate a smooth transition of your course, we require the following health information.

Do you have any past/present- physical health condition? (if yes, give complete details such as meditation, dosage, treatment, hospitalization etc) : YesNo

Health Details : * [If No, Write 'Unknown']

Do you have any past/present of psychological treatment? (if yes, give details.) YesNo

Psychological Details : * [If No, Write 'Unknown']

Any past addiction of tobbacco, Alcohol or Drugs? (If yes, Give details) YesNo

Past Tobbacco Details? : * [If No, Write 'Unknown']

Any current use of tobbacco, Alcohol or Drugs(Specify Substance, frequency and last use) YesNo

Current Tobbacco Details? : * [If No, Write 'Unknown']

Dou have any past/present experience with Reiki, Spiritual healing or any other meditation practices? If yes, give details: YesNo

Reiki Details? : * [If No, Write 'Unknown']