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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
Gender* MaleFemale
Given / First name in English*
Surname / Family / Last name in English *
ID Number*
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Age*
Date of Birth*
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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?*
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.*