Cakkavala Meditation Centre
Meditation Retreat conducted by Sayalay Dipankara from 30th August 2008 - 7th September 2008
Retreat Application Form
禪修營報名表格

For full-period (30th August 2008 - 7th September 2008) participants only

 

NOTE: Please type "NIL" for fields not applicable for you. Thank you.

Personal Particulars
Full Name / 姓名:
Age / 年龄:
Sex / 性别:
Nationality / 国籍:
Passport # / 护照号码:
Member of Cakkavala Meditation Centre / 会员:
Taken 5 Precepts / 已受五戒:
Religion / 宗教:

Date of Expiry (Passport):
/ / (DD/MM/YYYY)
Contact No. /联络号码:
Email /电邮:
Address /地址:

Meditation Experience / 禅坐经验:
Yes / 有 ( Years / 年) No / 无
Meditation Method (方法):
Teacher's Name(老师):

 

In case of Emergency, Person to Contact / 紧急联络人
Name / 姓名:
Relationship / 关系:
Contact No / 联络号码:
Health and Mental Status / 身心状况
Health problem / 健康方面:
If yes, please give details / 如有， 请说明:
Mental Problem / 精神问题:
If yes, please give details / 如有， 请说明:
Diagnosis / 病症:
Currently under Medication /目前是否在治疗:
Any relapse over the last 1 year / 过去一年，病情可曾复发:
Date of last review (by Doctor) / 最后一次医生检验日期: / / (DD/MM/YYYY)

 

Other Information you wish the Teacher to know / 其他我希望让导师知道的资料:

I hereby declare that all the above information is true and I agree to abide by the Meditation instructor's advice and the retreat's rules and regulations, otherwise I will leave on my accord. I also understand that the organisers will not be responsible in the event of any mental or physical injury incurred during the retreat.
本人在此声明以上所填资料全属真实。在禅修期间，本人将服从导师的教导并遵守道场的所有规定。本人也明白主办团体将不负责任何本人在禅修期间所发生的一切身心健康状况。