Vipassana Meditation - Course Application Form

IMCUSA Course Application Form Any information given here will be treated in the strictest confidence

If you would like to attend a ten day Vipassana meditation course in the Tradition of Sayagyi U Ba Khin please first read our Guidelines and Instructions During a Ten-Day Retreat and choose a course date before you complete this application form. If the course site does not have Email or if you would prefer not send your details over the internet, then please Download Application Form in PDF format and mail it to the relevant address given in the Address section. Please note that this application form is for IMC-USA only, in Westminster, Maryland. If you wish to apply for a course at one of our other centers, go to the international application page.

I would like to attend the Meditation course from: to:

Surname:                          
First Name(s):                    
Gender:                           Male  Female

Date of birth:                    
Occupation:                        
Nationality:                      
Language(s)spoken:                
Do you understand English well?  Yes  No

Full Postal address:
Line 1
Line 2
Line 3
Line 4
Line 5

Telephone: 
Mobile:    
Fax:        
Email:

Please give details of someone to contact in the event of accident or illness:

Name:        
Address:     
Telephone:

1. Have you attended courses in the Sayagyi U Ba Khin tradition before? Yes No
a) If yes, please say when, where and name of the Teacher of your most recent course.

b) If no, have you practised any other techiques of meditation? Yes No

2. a) Are you in good physical and mental health? Yes No
If no, please give details.

b) Are you undergoing a course of medical treatment and/or will you be taking
any medication at the time of the meditation course? Yes No
If yes, please give details of medication.

c) Do you suffer from any serious food allergy? Yes No
If yes, please give details.

3. How did you come to know about this Center and meditation course?
Please name the magazine, website, friend, poster etc. from which you learned of the IMC.

All information will be kept strictly confidential.

Please note that we ask each student to contribute toward food and accommodation for a ten-day course.