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Application Form

DhammaJava

Have you completed a 10-day course with S.N. Goenka or any of his assistant teachers?*
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Primary Language* Profiency Level*

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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?*
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No

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

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

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

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