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Course Date

Teacher Information

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

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

English :
Hindi:

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?:

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) :
Do you have any past/present of psychological treatment? (if yes, give details.)
Any past addiction of tobbacco, Alcohol or Drugs? (If yes, Give details)
Any current use of tobbacco, Alcohol or Drugs(Specify Substance, frequency and last use)
Dou have any past/present experience with Reiki, Spiritual healing or any other meditation practices? If yes, give details:
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