Use this form to apply for a Vipassana meditation course. It can be printed out and either faxed, "snail-mailed" or sent by email.
To apply by email, fist copy and paste the form below into a word processing document or blank email. Fill in the spaces, then just send the email or cut and paste the completed form from your word processor into an email.
If you are unable to use this on-line application form, please contact the applicable Center or Non-Center course location and request an application form by mail.
To apply for a Vipassana course in Mexico, send your application to: email@example.com
Please answer all questions fully. All information will be kept strictly confidential.
Vipassana Application Form
CENTER OR OTHER COURSE LOCATION: ___________;
COURSE DATES:(from) __________(to) __________;
TYPE OF COURSE (10 DAY, ETC.): ________________________;
FIRST NAME: ______________________________________;
LAST NAME: ______________________________________;
ADDRESS (Street/P.O. Box): __________________________;
(State/Prov. & Country): __________________;
(Zip or Postal Code): ________________;
E-MAIL ADDRESS: ____________________________;
TELEPHONE NUMBERS: (Work) ( _____) ___________;
(Home) ( _____ ___________;
(Fax) ( _____) ___________;
DATE OF BIRTH: ________________;
I am driving and willing to be contacted by other students seeking a ride to the course.
YES ____; NO ____.
Do You understand English very well? YES ____; NO ____;
If no, please explain (extent of English, native language, other languages).
Have you previously attended a course with S.N. Goenka or any of
his authorized assistant teachers? NO ____; YES ____;
If yes, please give following details:
FIRST COURSE INFORMATION:
MOST RECENT COURSE INFORMATION:
TOTAL NUMBER OF COURSES:
Other courses sat (specify _______________________;
Served Fulltime ______;
1) What previous experience, if any, have you had with meditation techniques, therapies or healing practices?
2) How did you learn about Vipassana, or who introduced you to this course?
___ Book/Magazine (which one? _______________);
___ News Article (which paper? ______________);
___ Poster (where? _____________);
___ Internet (which site? ______________);
___ Friend/Word of Mouth (name? ______________);
___ Other (What? _________________);
___ Who introduced you? ( _________________________).
1) Have you practiced any other meditation techniques (including other types of Vipassana) or other therapeutic or healing techniques since your last course with S.N. Goenka or his assistant teachers?
2) Have you maintained your practice of Vipassana Meditation since your last course?
NO ____; YES ____;
3) Would you be willing to come early to help with set-up if needed? NO ____; YES ____.
4) Would you be willing to serve this course should the need arise? NO ____; YES ____.
5) If you are not attending the entire course, please give your arrival date and hour: __________________;
and departure date and hour: __________________.
NEW AND OLD STUDENTS:
1) Do you have any physical health problems, medical conditions or diseases? NO ____; YES ____.
If yes, please give details (dates, symptoms, duration, treatment, present condition).
2) Do you have or have you ever had any mental health problems such as, significant depression or anxiety, panic attacks, manic depression, schizophrenia, etc.?
NO ____; YES ____.
If yes, please give details (date, symptoms, duration, hospitalization, treatment, present condition).
3) Are you now taking, or have you taken within the last two years, any prescribed medication?
NO ____; YES ____.
If yes, please give details (dates, types, dosage, present use).
4) Are you now taking, or have you taken within the last two years, any alcohol or drugs (such as, marijuana, amphetamines, barbituates, cocaine, heroin, or other intoxicants)?
NO ____; YES ____.
If yes, please give details (dates, types, amounts, treatment, present use).
By completing the spaces set forth below with my name and the date, I hereby acknowledge that I have carefully read and understood the Code of Discipline for the Vipassana Meditation course for which I am applying. I agree to stay on the course site and to abide by all the rules and regulations for the duration of the course. I realize that a Vipassana Meditation course is a serious undertaking that will require my full mental and physical health and I affirm that I am fit to participate in it. I hereby certify that the above information is true and correct to the best of my knowledge.
Either print and mail or fax this document to the Center or Non-Center course location at which the course for which you are applying is to be conducted. If this on-line application cannot be successfully downloaded and completed, please contact the applicable Center by phone, fax or E-Mail and request an application form by mail.
For Vipassana courses in Mexico, email this application to:
For regular mail:
Asociación Vipassana de México A.C.
Potrero Verde 201-6
C.P. 62420 Cuernavaca, Morelos, México
For More Information
For Other courses, check on the Vipassana website for the email address