Course DateStarting DateDaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923Ending DateDaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923SelectDhamma Giri, IgatpuriDhamma Sarita, KhadavaliDhamma Anakula, AkolaDhamma Punna, PuneDhamma Nashika, NasikTeacher InformationName *Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweAgeGenderMaleFemaleMobile NumberLandlineEmail AddressPhoto ID TypePassportAdhar CardPan CardVoter IDOtherPhoto ID NumberEducationPh.DS.S.C D.EdName of SchoolSchool AddressDesignationOption 1Option 2Will friend or family member be taking this course as well? IF yes, write Name(s) and Relationship.YesNoEMERGENCY 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 : NoneBasicIntermediateExpertHindi:NoneBasicIntermediate ExpertLanguages you are fluent inFor 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?: YesNoFor 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) : YesNoHealth Details : * [If No, Write 'Unknown'] Do you have any past/present of psychological treatment? (if yes, give details.) YesNoPsychological Details : * [If No, Write 'Unknown'] Any past addiction of tobbacco, Alcohol or Drugs? (If yes, Give details) YesNoPast Tobbacco Details? : * [If No, Write 'Unknown'] Any current use of tobbacco, Alcohol or Drugs(Specify Substance, frequency and last use) YesNoCurrent 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: YesNoReiki Details? : * [If No, Write 'Unknown'] Submit