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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