Course Application Form

I would like to attend the Meditation course from (please click the arrow below to select your correct dates from the drop down menu):
23 Oct 2026 - 02 Nov 2026

Surname*:

First Name(s)*:

Gender:
MaleFemale

Date of Birth*:
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Place of Birth*:

Nationality*:

Languages(s)*:

Do you understand English well?
YesNo

Marital Status*:

Occupation*:

Telephone*:

Fax:

Your Email*:

Full Postal address:

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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?
YesNo

If Yes, please list where and when and give the name of the teacher(s):

Are you presently in good physical and mental health?:
YesNo

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?:
YesNo

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?:
YesNo

Has there been any major upheaval in your life recently?:
YesNo

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:

To successfully lodge the form you must ensure that all fields are completed.
When the form is sent successfully a message will be shown at the bottom of the page.
If you sent the message successfully and have had no reply from the Centre within a week, please contact us by email or telephone to ensure your form has been received.