Application Form

Dhamma Andalas (10 Day Course) - 12th May, 2021

Have you completed a 10-day course with S.N. Goenka or any of his assistant teachers?
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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?
Do you have any physical health problems, medical conditions or diseases?
Do you have, or have you ever had, any mental health problems such as significant depression or anxiety, panic attacks, manic depression, schizophrenia, etc.?
Are you now taking, or have you taken within the past two years, any prescribed medication?
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.)
Will a friend or family member be taking this course as well?
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.