Students are expected to stay for the entire 10 day course unless
different prior arrangements have been made.

If you wish to apply to attend for less than 10 days, please put details below:

Have you attended courses in the Sayagyi U Ba Khin tradition before?:
Yes
No
If Yes, please list where and when and give the name of the teacher(s):

Are you presently in good physical and mental health?:
Yes
No
If No, please give us details (brief) :

Are you undergoing a course of medical treatment and/or are you taking
any medication at the time you will attend the course in Vipassana meditation?:
Yes
No
If Yes, please list the medication and the purpose for which it was prescribed:

Please tell us if you had any major physical or mental illness in the past:

Have you ever had a significant problem as a result of drugs or alcohol?:
Yes
No

Has there been any major upheaval in your life recently?:
Yes
No
If Yes, please give details

If there is anything you wish to add or bring to the attention of the
Teacher and/or the management then please note it here.