TISARANA VIHARA MEDITATION CENTRE
357 NELSON ROAD, WHITTON, TWICKENHAM
MIDDLESEX, TW2 7AG, U.K. TEL/FAX: 020 8898 6965

APPLICATION FORM FOR MEDITATION RETREAT
(http://www.nibbana.com/mediapli.htm)

  1. Name:

  First and Middle:

  Last:

  2. Address:

Post Code:                  

  Telephone: Home/ Mobile:
  Work (Day Time):

  3. Contact
  (In case of Emergency)

  Name:

  Telephone No:

  4. Which course do you want to apply for?

(a) First Choice ( Please Tick)
April 13-22=10 days Course [ ]
August 25-27=3 days Course [ ]
December 22-31=10 days Course [ ]

  (b) Second Choice ( Please Tick)
April 13-22=10 days Course [ ]
August 25-27=3 days Course [ ]
December 22-31=10 days Course [ ]

  5. Please give exact dates if relevant:

  Start Date:

  Finish Date:                    Total:          days.

  6. Any previous experience of Meditation?

  Yes [   ]      No [   ]
  Please give details if 'Yes.'

  7. Do you have any serious health problem or medical condition that might affect your meditation?


  8. Do you need any special arrangement during your stay, e.g., vegetarian diet, medication, etc.,?


  9. Name of any Religious organisations you are associated with:


  The rules of Meditation Centre include observation of the Eight Precepts, such as abstaining from food after mid-day, alcohol, drugs and smoking. Strict observation of Noble Silence is practised during the retreat.

  I, ....................................................., agree to abide by the rules of Tisarana Vihara Meditation Centre, practise diligently and follow closely the instructions of the Meditation Teacher.

  Signature:


 

  Date: