MINDFULNESS MYANMAR RETREAT APPLICATION

Once the retreat is filled, 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

Male
Female

Address

City

State/Provence/Territory

Country

Telephone

Website

Facebook

Skype

Best days and times to reach you

Birth Date (yyyy-mm-dd)

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?

Vegetarian
Non-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?

I hereby certify that all of the information contained in this application is complete and accurate to the best of my knowledge. I understand that, if accepted, omissions or false statements on this application shall be considered sufficient cause for dismissal. I will not hold the Buddha Sasana Foundation or Mahasi Sasana Yeiktha Meditation Centre responsible for any liability during my travel or stay for this retreat.

Name