Application Form

DhammaJava

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

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

Have you completed a Children's or Teen's course with S.N. Goenka or any of his assistant teachers? *
Yes
No

Gender*
Male	Female

Firstname*

Lastname*

Age*

Date of Birth*

Country*
-- Select Your Country -- Indonesia

Region*

-- Select Your Region -- 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*

Indonesian Profiency
-- None -- Beginer Intermediate Expert

English Profiency
-- None -- Beginer Intermediate Expert

Mobile Phone*
+

Standard / Grade (For Children/Teenager)

Which school or college do you attend? (For Children/Teenager)

Emergency's / Parent's Name*

Emergency's / Parent's Contact*
+

Your Email or Parents email*

*We use this email to contact you or your parents

Have you learned any other types of meditation?*
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

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