Due to the uncertainty surrounding the current pandemic, we ask you to please contact us before submitting a registration form. Please first read our Course Guidelines and choose a course date before you complete this application form. Please note that this application form is for IMC - USA only, in Westminster, Maryland. NB: If you do not hear from us within three days of applying, please call 410-346-7889 and leave a message. Fields marked with * are required. IMC Course Application Form I wish to attend the Meditation Course to be held from: * March 12 – 22, 2021 May 14 – 24, 2021 June 11 – 21, 2021 August 13 – 23, 2021 October 8 – 18, 2021 December 24 – January 3, 2022 Last Name * First Name * Email * Enter Email Confirm Email * Confirm Email Your Message Date of Birth * Occupation Gender * Female Male Country of Nationality * United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d‘Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Street Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Option 52 Option 53 ZIP Code * Phone Number * Cellphone Emergency Contact Information Name Phone Number Street Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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? Website Magazine Poster Word of mouth OtherOther 7. Anything you would like to bring to our attention? reCAPTCHA If you are human, leave this field blank.