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Registration Form
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Program Name
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Program Date
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Name
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First
Last
Primary Language
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Gender
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Age
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15 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 - 79
80 +
Occupation
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Phone Number
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Email
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Emergency Contact: Name/Relationship/Telephone
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Do you have meditation experience? If yes, please provide brief detail of your experience.
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Do you have any mental or physical illnesses which could affect your ability to meditate? If yes, please give brief details.
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Are you taking any drugs or treatment? If yes, please give brief details below.
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Do you speak English well?
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I understand and agree that with my participation, I am willingly and knowingly accept full responsibility for all my actions in thought, speech and deed. The information I have given is true to the best of my knowledge.
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I agree with the above statement.
Disclaimer:
These information will be kept confidential and is going to help us provide a safe environment for you and others.
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Home
About us
Meditation
SADDHĀ & SILĀ
SAMĀDHI & PAÑÑĀ
Services
Generosity
Building Project
Upcoming Events
Community
Connect
Read More