RETREAT APPLICATION
Name (Exactly as it appears on your passport)--------------------------------
Sex: Female------ Male--------
Address---------------------------------------------------------------------
City -----------------------------State----- Zip Code ----------- Country----
Phone ( )--------------------------------
Email:--------------------------------
Date of Birth ------------------------------------------------
Passport No.--------------------------------------------------
Country on Passport ---------------------------------------------------------
Occupation:------------------------------------------------------------------
Emergency Contact:
Name ----------------------------------Relationship---------------------------
Address --------------------------------------------------------------------
Phone ( )--------------------------Email----------------------------------
If you have attended meditation retreats in the Theravadan tradition
please
list them below
Date Teacher Location Length of retreat
Please list any other meditation traditions you have practiced in the
last 5 years.
Please be thorough and honest in your answers to the questions below
so that the
Sayadaws can most skillfully guide your practice.
1. Do you have any history of physical illness, limitations or special
needs,
which might affect your stay in Burma, or an illness that requires constant
treatment? If so, please be specific.
2. Are you currently taking any drugs or medications? Please list each
medication and the condition being treated.
3. Have you ever been diagnosed with a psychological condition? Please
describe
the diagnosis, treatment given, (including medications), and the dates.
4. Have you ever experienced or been treated for moderate or severe
depression
or a nervous breakdown? If yes, please list the date(s). Has the condition
been
resolved ?
5. Have you ever attempted to take your life? Yes------ No-------
If yes, please describe the circumstances and dates.
6. What is your purpose in wanting to participate in this retreat? State
your purpose clearly.
PLEASE READ CAREFULLY AND SIGN BELOW:
I hereby certify that all of the information contained in this application
is
complete and accurate to the best of my knowledge. I understand that,
if
accepted, omissions or false statements on this application shall be
considered
sufficient cause for dismissal. I will not hold Panditarama responsible
for any
liability during my travel or stay for this retreat.
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Signature of applicant Date signed |