IMC - USA Course Application Form - International Meditation Center

I wish to attend the Meditation Course to be held from: *

Last Name *

First Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Your Message

Date of Birth *

Occupation

Gender *

Female

Male

Country of Nationality *

Street Address *

City *

State *

ZIP Code *

Phone Number *

Cellphone

Emergency Contact Information

Name

Phone Number

Street Address

City

State

ZIP Code

End Section

1. Have you attended courses in the Sayagyi U Ba Khin tradition before?

Yes

No

If yes, when and where was your most recent course?

2. Are you currently practicing any other techniques of meditation?

Yes

No

If yes, for how long have you been practicing them?

3. Are you in good physical and mental health? *

Yes

No

If no, please give details on your condition. If yes, enter N/A in this box. *

4. Are you currently under a doctor's care for any condition, medical or otherwise? *

Yes

No

If yes, please describe, including the medications you are taking. If no, enter N/A in this box. *

5. Do you suffer from any serious food allergies? *

Yes

No

If yes, please provide details. If no, enter N/A in this box. *

6. How did you learn about this Center and the meditation course?

7. Anything you would like to bring to our attention?

reCAPTCHA