APPLICATION FORM

Ashin Tejaniya – mindfulness meditation (vipassana) course

23.4. to 8.5.2011

PERSONAL INFORMATION

(Please answer all questions in full. All provided information will be handled as strictly confidential.)

Name	Surname	Gender	Male Female
Date of birth (format: 29.10.1977)	Nationality	Do you require pensioner / student discount?	Yes No
Phone (cellular/mobile preferrable) (format: +420.777111222)	E-mail address	Occupation / Profession:	Passport/identity card number
Street + number	City	ZIP code	Country

QUESTIONNAIRE:

When do you want to come for the reterat? 1st week (Sat 23th Apr - Sat 30th Apr - 7 days) 2nd week (Sat 30th Apr - Sun 8th May - 8 days) other (specify the dates)

Have you ever attended any vipassana course before?	Yes	No
If YES, please fill in year and teacher, when it was at first:	Year and teacher, when it wast at last

Do you practice meditation regularly? (If yes, please state how often and medit. technique or name of the teacher)	Yes	No
Technique/ type of meditation / teacher Since when (year)	How often do you meditate:

Are you in contact with any group or organization whereby you practice meditation together with others?	Yes	No
If yes, please state the group’s name	How often do you meet with the group

Are you sufficiently fit both physically and mentally?	Yes	No
If not please describe your condition briefly (please also state if you are pregnant)

Can you come earlier and help with preparations, if needed?	Yes	No

Five precepts are to be followed during the course (to abstain from doing harm or killing, stealing, sensual or sexual misconduct, lying or causing harm by speach, using intoxicants). Do you wish to follow 8 precepts? (to abstain from eating after midday, entertainment and self-adornment, and luxurious beds)	Yes	No

Do you wish to book a room with a shower and toilet en suite? (extra EUR 20 for 2 weeks)	Yes	No

If coming by car, can you give a drive to other attendants or help with bringing equipment to the place?	Yes	No

To practice mindfulness in daily activities, I also wish to take part in chores (helping in kitchen, cleaning, ringing the bell etc.) Daily I can give it:	cca 40 min cca 20 min	cca 5 min None

Do you understand spoken english??	Yes A little	No

Where did you learn about the course ? (you can tick several options): From the organizers Friend (Name?) Internet (site?) Leaflet / Noticeboard (Where?) Other (please specify)
Note

I hereby confirm that I know and understand the rules of the meditation course (mainly keeping of the 5 precepts and of noble silence) and agree to follow them during the entire course. (Should you have any questions or doubts please contact the organizer). I undertake to follow the teacher’s meditation instruction and not to combine it with other techniques during the course. I further confirm that I am of good enough physical and mental health to attend the course. I undertake to care for my physical and mental condition and, if problems occur, to contact the teacher immediately in order to find the best solution. I understand and accept that neither the teacher nor the organizers accept any responsibility for any physical or mental problems that might occur during or after the course. I agree with the cancellation terms given hereinafter. I confirm I answered all questions in full and truly.

I also udertake to pay the deposit of EUR 100 within 7 days to the account bellow:
Bank details for international money transfer: Bank name: Ceska sporitelna // Bank address: Panska 12/14, 602 00 Brno, Czech republic // IBAN = CZ74 0800 0000 0010 8096 2043 // SWIFT (BIC) code = GIBA CZ PX
Variable symbol = your date of birth in formate YYMMDD (YearMonthDay), e.g.: 26.03.1974 = 740326

SUBMITTED APPLICATION FORM AND PAID DEPOSIT ARE NECESSARY FOR YOUR REGISTRATION ! (You will sign your application form at the beggining of the course)

CANCELLATION TERMS: if cancelling your registration, following cancellation fee is charged:
More than 40 days before course>> EUR 20 // 40 to 21 days before course>> EUR 35 // 20 to 10 days before course>> EUR 45 // less than 10 days before course >> EUR 65

A month before the course you will obtain detailed information (what to bring, transportation. ..etc.).

Please contact us if you have any questions. Regards and metta, Adam Doleží // mobile.: +420 775 072 611 // vipassana.course@gmail.com.