Application Form

DhammaJava

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


Gender*
Male Female


Firstname*

Lastname*

ID Number*

Upload Photo
Max file size 2MB

Age*

Date of Birth*

Country*

Region*

Address*

City*

ZIP / Postal / Pin Code

Primary Language*
Profiency Level*

Indonesian Profiency

English Profiency

Email*

Mobile Number*

Home Phone

Work Phone

Education

Occupation

Company Name

Departement

Company Designation

Emergency Contact Name*

Emergency Phone*

Emergency Contact Relationship to You*

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

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