Thanti-Thitsar Vipassana Meditation Center
(TTVMC)

Visitors' Form for Retreats
 

Please fill out this form completely and then click the submit button. Please read the amended policy under registration.
* required information

First name  *
 		Middle name
Last name  *
 
Address  *
 		City  *
State  *

Zip Code.

Country  *
E-mail  *
Telephone
Who is your meditation teacher
 		Stay from : *
   Example: 25/07/2002
To  : *
   Example): 30/07/2002

Have you meditated before?  *

 

Please describe *
 
Age and sex *....................
Date of Birth * ..................
Social Security # *........ ......
Driver License # *...............
Emergency contact (Relative, or Friend) *..........................
Emergency Telephone #*.....................................

Do you have any disease that may affect your meditation practice or stay at the monastery? *

If "yes", specify 

Who is your family doctor?

   

I declare that all the information given in this form is true and correct. During my stay at the TTVMC, I accept to follow all the rules (as described in the web) and to be under the supervision of the Theravada monk or the person assigned for that purpose. I also understand that neither TTVMC nor the Board members  will be responsible in the event of any illness, injury, or accident incurred during my stay in the TTVMC.

 
I accept the rules
  Yes   No
 

(VF)
 13-01-2006 04:48:31 PM