MINDFULNESS MYANMAR RETREAT APPLICATION

Once the retreats fill, a notice will be posted on this site and a waiting list will be started.
Please fill out the application carefully and we’ll get back to you in a day or two.

Full Name as Appears on Your Passport (First, Middle, Last)

Sex? MaleFemale

Address

City

State/Provence/Territory

Country

Telephone

Email

Website

Facebook

Skype contact

Best days and times to reach you:

Birth Date (yyyy-mm-dd)

Passport Number

Country on Passport

Date of expiration (yyyy-mm-dd)

Where do you plan to get your 28 day tourist visa to Myanmar?

Occupation

Emergency Contact Name, Relationship to You

Contact Address (City, State, ZIP & Country)

Emergency Contact Phone & Email

Please list meditation retreats you've attended in the past (including those not in the Theravada tradition). Include: Date, Teacher, Location, and Retreat Length.

What is your purpose in wanting to participate in this retreat? Please elaborate clearly.

What (if any) psychological and mental health issues have you had in your life, past or present?

Please list any medication you are currently taking for these issues.

Do you wish to have vegetarian or non-vegetarian meals during your retreat? VegetarianNon-vegetarian

Please list any dietary restrictions that are essential for you during the retreat.

Do you have any special needs or concerns that we should be aware of?

How did you learn of the retreats? Or, who referred you to them?