Application Form

DhammaJava

During this time of the Coronavirus pandemic, we are striving to operate as safely as possible, for you and everyone at the meditation center. Please respond to the following questions as fully and clearly as possible. We may contact you for further information to clarify your situation. Although the center is taking all precautions, there is no guarantee that COVID-19 does not appear at the center. Please note certain conditions may increase the risk of serious illness from Coronavirus. These conditions include: - Age over 65 years - Chronic lung disease or moderate to severe asthma - Serious heart conditions - Immuno-compromise (e.g. from cancer treatment, smoking, bone marrow or organ transplant, immune deficiency, poorly controlled HIV or AIDS, or prolonged use of corticosteroids and other immune weakening medications) - Severely overweight (body mass index [BMI] of 40 or higher) - Diabetes Chronic kidney disease undergoing dialysis - Liver disease - Pregnancy If you have any of the above conditions, it is advised that you not place yourself at risk to COVID-19 by attending a course at this time.

Please note: You must provide full, complete and detailed answers to ALL QUESTIONS in order for your application to be considered. Please give an honest and complete answer to each question. * means required to be fill.

Have you completed a 10-day course with S.N. Goenka or any of his assistant teachers?*
Yes	No

How many times have you completed the 10 days course? *

Gender*
Male	Female

Please choose what you are applying to do*
Attend the course
Serve the course

Given / First name in English*
Surname / Family / Last name in English *
ID Number*
Upload Photo
Max file size 2MB
Age*
Date of Birth*
Day 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st Month January February March April May June July August September October November December Year 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922
Country or Region*
Select Country or Region Venezuela VE Australia AU Belize BZ Canada CA India IN Ireland IE Jamaica JM New Zealand NZ Philippines PH South Africa ZA Trinidad And Tobago TT United Kingdom GB United States US Afghanistan AF Aland AX Albania AL Algeria DZ American Samoa AS Andorra AD Angola AO Anguilla AI Antarctica AQ Antigua And Barbuda AG Argentina AR Armenia AM Aruba AW Austria AT Azerbaijan AZ Bahamas BS Bahrain BH Bangladesh BD Barbados BB Belarus BY Belgium BE Benin BJ Bermuda BM Bhutan BT Bolivia BO Bonaire BQ Bosnia And Herzegovina BA Botswana BW Bouvet Island BV Brazil BR British Indian Ocean Territory IO Brunei Darussalam BN Bulgaria BG Burkina Faso BF Burundi BI Cambodia KH Cameroon CM Cape Verdi CV Cayman Islands KY Central African Republic CF Chad TD Chile CL China CN Christmas Island CX Cocos (Keeling) Islands CC Colombia CO Comoros KM Cook Islands CK Costa Rica CR Croatia HR Cuba CU Curaçao CW Cyprus CY Czech Republic CZ Côte d'Ivoire CI Democratic Republic of the Congo CD Denmark DK Djibouti DJ Dominica DM Dominican Republic DO Ecuador EC Egypt EG El Salvador SV Equatorial Guinea GQ Eritrea ER Estonia EE Ethiopia ET Falkland Islands FK Faroe Islands FO Federated States of Micronesia FM Fiji FJ Finland FI France FR French Guiana GF French Polynesia PF French Southern Territories TF Gabon GA Gambia GM Georgia GE Germany DE Ghana GH Gibraltar GI Greece GR Greenland GL Grenada GD Guadaloupe GP Guam GU Guatemala GT Guernsey GG Guinea GN Guinea-Bissau GW Guyana GY Haiti HT Heard and McDonald Islands HM Honduras HN Hong Kong HK Hungary HU Iceland IS Indonesia ID Iran IR Iraq IQ Isle Of Man IM Israel IL Italy IT Japan JP Jersey JE Jordan JO Kazakhstan KZ Kenya KE Kiribati KI Kuwait KW Kyrgyzstan KG Laos LA Latvia LV Lebanon LB Lesotho LS Liberia LR Libya LY Liechtenstein LI Lithuania LT Luxembourg LU Macau MO Macedonia MK Madagascar MG Malawi MW Malaysia MY Maldives MV Mali ML Malta MT Marshall Islands MH Martinique MQ Mauritania MR Mauritius MU Mayotte YT Mexico MX Moldova MD Monaco MC Mongolia MN Montenegro ME Montserrat MS Morocco MA Mozambique MZ Myanmar MM Namibia NA Nauru NR Nepal NP Netherlands NL New Caledonia NC Nicaragua NI Niger NE Nigeria NG Niue NU Norfolk Island NF North Korea KP Northern Mariana Islands MP Norway NO Oman OM Pakistan PK Palau PW Palestine PS Panama PA Papua New Guinea PG Paraguay PY Peru PE Pitcairn PN Poland PL Portugal PT Puerto Rico PR Qatar QA Republic of Congo CG Reunion RE Romania RO Russia RU Rwanda RW Saint Barthélemy BL Saint Helena SH Saint Kitts-Nevis KN Saint Lucia LC Saint Martin MF Saint Pierre And Miquelon PM Saint Vincent And The Grenadines VC Samoa WS San Marine SM Sao Tome And Principe ST Saudi Arabia SA Senegal SN Serbia RS Seychelles SC Sierra Leone SL Singapore SG Sint Maarten SX Slovakia SK Slovenia SI Solomon Islands SB Somalia SO South Georgia And The South Sandwich Islands GS South Korea KR South Sudan SS Spain ES Sri Lanka LK Sudan SD Suriname SR Svalbard And Jan Mayen SJ Swaziland SZ Sweden SE Switzerland CH Syria SY Taiwan TW Tajikistan TJ Tanzania TZ Thailand TH Timor-Leste TL Togo TG Tokelau TK Tonga TO Tunisia TN Turkey TR Turkmenistan TM Turks And Caicos Islands TC Tuvalu TV Uganda UG Ukraine UA United Arab Emirates AE United States Minor Outlying Islands UM Uruguay UY Uzbekistan UZ Vanuatu VU Vatican City VA Vietnam VN Virgin Islands Virgin Islands Wallis And Futuna WF Western Sahara EH Yemen YE Zambia ZM Zimbabwe ZW
State or Province*
-- Select Your State or Province -- Aceh Bali Bangka Belitung Islands Banten Bengkulu Central Java Central Kalimantan Central Sulawesi East Java East Kalimantan East Nusa Tenggara Gorontalo Jakarta Jambi Kalimantan Lampung Lesser Sunda Islands Maluku Maluku Islands North Kalimantan North Maluku North Sulawesi North Sumatra Papua Riau Riau Islands South Kalimantan South Sulawesi South Sumatra Southeast Sulawesi Special Region of Yogyakarta Sulawesi Sumatra West Java West Nusa Tenggara West Papua West Sulawesi West Sumatra
Address*
City*
ZIP / Postal / Pin Code
Primary Language
Select Language English en Indonesian id --------------------------------------------------------------------------------------------- AbkhazianAfarAfrikaansAkanAlbanianAmharicArabicArabic - AlgeriaArabic - BahrainArabic - EgyptArabic - IraqArabic - JordanArabic - KuwaitArabic - LebanonArabic - LibyaArabic - MoroccoArabic - OmanArabic - QatarArabic - Saudi ArabiaArabic - SyriaArabic - TunisiaArabic - United Arab EmiratesArabic - YemenAragoneseArmenianAssameseAustralian EnglishAustrian GermanAvaricAvestanAymaraAzeriBambaraBashkirBasqueBelarusianBengaliBihariBislamaBosnianBrazilian PortugueseBretonBritish EnglishBulgarianBurmeseCanadian EnglishCanadian FrenchCatalanChamorroChechenChineseChinese - ChinaChinese - Hong Kong SARChinese - Macau SARChinese - SimplifiedChinese - SingaporeChinese - TaiwanChinese - TraditionalChurch SlavicChuvashCornishCorsicanCreeCroatianCzechDanishDivehiDutchDutch - NetherlandsDzongkhaEnglishEnglish - BelizeEnglish - CaribbeanEnglish - IndiaEnglish - IrelandEnglish - JamaicaEnglish - New ZealandEnglish - Southern AfricaEnglish - TrinidadEnglish – PhilippinesEsperantoEstonianEweFaroeseFijianFinnishFlemishFrenchFrench - BelgiumFrench - FranceFrench - LuxembourgFulahGaelic - IrelandGalicianGandaGeorgianGermanGerman - GermanyGerman - LiechtensteinGerman - LuxembourgGreekGuaraniGujaratiHaitianHausaHebrewHereroHindiHiri MotuHungarianIberian PortugueseIberian SpanishIcelandicIdoIgboIndonesianInterlinguaInterlingueInuktitutInupiaqIrishItalianItalian - ItalyItalian - SwitzerlandJapaneseJavaneseKalaallisutKannadaKanuriKashmiriKazakhKhmerKikuyuKinyarwandaKirghizKomiKongoKoreanKuanyamaKurdishLaoLatinLatvianLimburgishLingalaLithuanianLuba-KatangaLuxembourgishMacedonianMalagasyMalayMalay - BruneiMalay - MalaysiaMalayalamMalteseManxMaoriMarathiMarshalleseMongolianNauruNavajoNdongaNepaliNorth NdebeleNorthern SamiNorwegianNorwegian BokmålNorwegian NynorskNyanjaOccitanOjibwaOriyaOromoOsseticPaliPersianPolishPortuguesePunjabiPushtoQuechuaRomanianRomanian - MoldovaRomanshRundiRussianRussian - MoldovaSamoanSangoSanskritSardinianScottish GaelicSerbianShonaSichuan YiSindhiSinhalaSlovakSlovenianSomaliSorbianSouth NdebeleSouthern SothoSpanishSpanish - ArgentinaSpanish - BoliviaSpanish - ChileSpanish - ColombiaSpanish - Costa RicaSpanish - Dominican RepublicSpanish - EcuadorSpanish - El SalvadorSpanish - GuatemalaSpanish - HondurasSpanish - MexicoSpanish - NicaraguaSpanish - PanamaSpanish - ParaguaySpanish - PeruSpanish - Puerto RicoSpanish - UruguaySpanish - VenezuelaSundaneseSwahiliSwatiSwedishSwedish - FinlandSwedish - SwedenSwiss FrenchSwiss High GermanTagalogTahitianTajikTamilTatarTeluguThaiTibetanTigrinyaTongaTsongaTswanaTurkishTurkmenTwiU.S. EnglishUkrainianUrduUyghurUzbekVendaVietnameseVolapükWalloonWelshWestern FrisianWolofXhosaYiddishYorubaZhuangZuluChoose
Occupation
Home Phone
Mobile Phone*
Work Phone
Email*
Please enter only correctly formatted email addresses. Enter multiple email addresses separated with a comma.
Emergency Contact Name*
Emergency Phone*
Emergency Contact Relationship to You*
-- None -- Mother(Ibu) Father(Ayah) Brother(Saudara Laki) Sister(Saudara Perempuan) Husband(Suami) Wife(Istri) Child(Anak) Friend(Teman)

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?*
Yes
No

Do you have any physical health problems, medical conditions or diseases?*
Yes
No

Do you have, or have you ever had, any mental health problems such as significant depression or anxiety, panic attacks, manic depression, schizophrenia, etc.?*
Yes
No

Are you now taking, or have you taken within the past two years, any prescribed medication?*
Yes
No

Are you now taking, or have you taken within the past two years, any alcohol or drugs (such as marijuana, amphetamines, barbiturates, cocaine, heroin, or other intoxicants) or mind-altering plants and substances (such as ayahuasca, peyote, LSD, etc.)*
Yes
No

Will a friend or family member be taking this course as well?*
Yes
No

By checking the box below, I acknowledge and agree that any and all information provided in this application for acceptance into a Vipassana Meditation course, or otherwise provided by me to the Vipassana organizations, may be used by the Vipassana organizations for their purposes consistent with their Privacy Policies, as amended from time to time.

Click here to download a PDF copy of Privacy Policy, Disclosures & Consents for non-Long Course applications.

Yes, I accept the terms of the Privacy Policy and the other terms of submission of this application form.*

Back