Application Form

Dhammabhoomi Vipassana Course

Have you completed a 7 day Teenager or 10 day Vipassana course with S.N. Goenka or any of his assistant teachers?
Please choose what you are applying to do
Select date
Prefix your country code. For eg +91 for India.
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Allowed types: jpg, jpeg.
Prefix your country code. For eg +91 for India.
Space, Comma, Dash(-) not allowed.
Is either your Father or Mother an Old Student of Vipassana as taught by Mr. S.N. Goenka?
Have you done a Children’s course or 70 mins course?
Person to contact if any emergency during the course
Prefix your country code. For eg +91 for India.
Space, Comma, Dash(-) not allowed.
Have you learnt any other type of meditation?
Do you have any physical health problem?
Have you ever had any mental health problem?
Are you taking any medication?
Will a friend or family member be taking this course as well?
By checking the box, I accept the seriousness of the rules and regulations. I wish to join the course. I have taken this decision on my own accord without any pressure. If accepted, I promise faithfully to stay for the entire seven days and abide by all the rules.
By checking the box, I acknowledge and agree that any and all information provided in this application for acceptance into a Vipassana Meditation course, or otherwise provided by me to the Vipassana organizations, may be used by the Vipassana organizations for their purposes consistent with their Privacy Policies, as amended from time to time.
Select date
Select date
Please indicate how many of the following courses you have successfully completed
By checking the box, I accept the seriousness of the rules and regulations. I wish to join the course. I have taken this decision on my own accord without any pressure. If accepted, I promise faithfully to stay for the entire seven days and abide by all the rules.
By checking the box, I acknowledge and agree that any and all information provided in this application for acceptance into a Vipassana Meditation course, or otherwise provided by me to the Vipassana organizations, may be used by the Vipassana organizations for their purposes consistent with their Privacy Policies, as amended from time to time.