Course Application Form

Please answer all the questions fully. The information you give will be kept confidential.

Please note that information sent over the Internet is not secure and is subject to interception by others during transmission. If you are concerned about the possibility of security risks of your confidential information while it is on the Internet, do not use this form. Instead submit it by fax on +39 049 8591249 or surface mail. You may download a PDF application form. Print and complete it. Then please send the form to the following address:

Centro Vipassana Dhamma Atala
Località Veriolo, Via Prov.le 12, Lutirano
50034 Marradi (FI) ITALY

By faxing or posting your application form it may delay the registration process by one to two weeks.

New student Old student

Chosen course:

Second choice:

Chosen course:

Second choice:

First name:

Last name:

Date of birth: / /

Gender:MF

Nationality:

Address:

Town:

County:

Country:

Postcode:

Telephone Numbers

Home: Work:

Mobile: Fax:

When to contact me:

Email:

Occupation:

Native language:

Other languages you understand well:

English language knowledge:

Have you maintained your practice of Vipassana since your last course?YesNo

Please give details (how much time daily, etc.):

Have you practised 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?YesNo

If yes, please give details:

Have you had any previous experience with meditation techniques, therapies or healing practices?YesNo

If yes, please give details:

Do you teach or practice on others?YesNo

If yes, please give details:

Can you come early to help with the set-up if needed?YesNo

Would you be willing to serve on the course should the need arise?YesNo

First course

Date: / Location: Teacher:

Last course

Date: / Location: Teacher:

Number of sat courses completed (excluding served courses)

10 day: Satipatthana: 20 day:

30 day: Other:

Served courses:

Number of served courses: Date of the last served: /

How did you learn about Vipassana?

Are you pregnant?YesNo

Do you have any physical health problems or medical concerns?YesNo

If yes, please give details (dates, symptoms, duration, treatment, present condition):

Do you have, or have you ever had, any mental health problems such as significant depression or anxiety, panic attacks, manic depression, schizophrenia, etc.?YesNo

If yes, please give details (dates, symptoms, duration, hospitalization, treatment, present condition):

Are you now taking, or have you taken within the past two years, any prescribed medication?YesNo

If yes, please give details (dates, types, dosage, present use):

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)?YesNo

If yes, please give details (dates, types, amounts, treatment, present use):

Will a friend, partner or family member be taking this course as well?YesNo

If yes, please specify names(s) and relationship(s):

Notes:

If you are driving to the course site do you have no objection to being contacted by others seeking transport?YesNo

If you are not attending the entire course, please give the date and time of your arrival:

and departure:

PRIVACY POLICY

The information you provide will be strictly confidential and treated, manually and electronically, in accordance with the "Data Protection Policy" document. Please note that these data may be communicated to other Vipassana centers, even abroad. However, they will not be divulged without your consent. You may request to have this data modified and/or corrected, or even deleted, by simply submitting a written request addressed to the Italian Vipassana Association, Via Guida Rossa, 7 - 35020 Ponte S. Nicolò (PD), as possessor of the data.

I CONSENT

I acknowledge that I have carefully read the Code of Discipline for the course. I agree to stay on the course site and to abide by all the rules and regulations for the duration of the course. I realise that participation in a Vipassana meditation course is a serious undertaking and confirm that I am in a reasonably good state of mental and physical health. To the best of my knowledge I have given true and complete answers to all the questions.

Please click on the "Submit Application" button to send your application form.