Register for a Meditation Course or Retreat

Personal Details
Name	*
Nationality	*
Country of current residence	*
E-mail	*
Date of birth	*
Ordained (monk/nun)? How long?	*
Gender	Female Male
Do you have a psychiatric history (Give details)	*
Are you on any medication (Give details)	*
Previous Experience
When was your first Buddhist teaching?	*
Buddhist course/retreat experience (dates, topics, teachers, locations)	*
Your religious/Buddhist tradition	*
Course/Retreat Registration
Which course/retreat do you wish to attend?	*
Preferred arrival date	*
Preferred departure date	*
Preferred accommodation (subject to availability)	*
Have you forwarded a deposit? If so, where to and how much?	*
February 3-week VBM (Vipassana) Retreat registrations ONLY...
I have read all of the VBM Retreat information on this website	Yes No
I meet all of the minimum qualifications to attend	Yes No
I agree to abide by all of the VBM Retreat Discipline	Yes No
Other Information
How did you first learn about Root Institute?
How did you first learn about this particular course/retreat?
Additional comments

Personal Details