Registration Form

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Program Name & Date *

Name *

First

Last

Primary Language *

Gender *

Age *

Occupation *

Phone Number *

Email *

Do you speak English well? *

Fluent Good Moderate Speak Little or not at all

Do you have meditation experience? If yes, please provide brief detail of your experience. *

Do you have any mental or physical illnesses which could affect your ability to meditate? If yes, please give brief details. *

Are you taking any drugs or treatment? If yes, please give brief details below. *

Emergency Contact: Name/Relationship/Telephone *

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. *

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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dhammanjali@gmail.com
902 RAE STREET,
REGINA, SK S4T 2B4
Canada

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