IMC - USA Course Application Form - International Meditation Center

I wish to attend the Meditation Course to be held from: * 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. Have you been fully vaccinated against COVID? *

Yes

No

4. 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. *

5. 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. *

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

Yes

No

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

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

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

reCAPTCHA