Cakkavala Meditation Centre
Meditation Retreat Conducted By Sayalay dipankara from 13 to 22 Dec 02
Retreat Application Form
For full-period (13th Dec to 22nd Dec 2002) participants only.
Name________________ Sex____ Nationality______________ Education___________________
Address__________________________Age ____ Occupation________ Employer_____________
Contact No._________________ Religion______________Taken 5 Precepts : Yes / No
(R)__________ (Pgr)__________ (0)__________ (Hp)__________ Email: ___________________
In case of emergency, person to contact
Name _____________ Relationship______________ Address _____________ Contact No_________
Health and Mental Status
Health problem__________ : [ ] Heart Disease/, [ ] Gastric ,
[ ] Hypertension, [ ] Contagious disease,[ ] Diabetes If yes, please give details ______________________
Mental Problem : [ ] Yes [ ] No .
If yes, please give details ______________________________________________________________
Diagnosis : ________________________________________________________________________
Currently under Medication : [ ] Yes [ ] No
Any relapse over the last 1 year : [ ] Yes [ ] No
Date of last review (by Doctor): ________________________________________________________
Other Information which you wish the Teacher to know :______________________________________
I hereby declare that all the above information is true and I agree to abide by the Meditation instructor's advice and the retreat's rules and regulations, otherwise I will leave on my accord. I also understand that the organisers will not be responsible in the event of any mental or physical injury incurred during the retreat.
Date________________ Signature ___________________________
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