I the undersigned would like to enroll in the Special Vipassana Retreat under
the guidance of Ven. Beelin Sayadaw from ________________ to __________________
at Tathagata Meditation Center.
Name: __________________________________________ _____Male ____Female
Last First
Address:___________________________________________________________________________
Phone: ___________________________________________________________________________
Age: ___20-30 ___30-40 ___ 40-50 ___ 50-60 ___Over 60
Emergency Contact: _____________________________ ____________ ________________
Name Phone Relation
Health Information: Good Health: ___ Yes ___ NO
If Not good, please state your current condition including disability and
mental problem: ________________________________________________________
Insurace coverage: ___ Yes ___ NO
If yes, what company: _________________________________________________
Previous Vipassana experience: ___ Yes ___ NO
Retreat donation to cover utility expenses ($25 a day):
Amount: $___________ ____ Cash ___ Check (check number: ___________)
I hereby certify that the information provided in this application is accurate to
the best of my knowledge. I understand that Tathagata Meditation Center is a
non-profitable organization and the retreat is organized solely for the benefit
of meditators like myself. Therefore, I waive Tathagata Meditation Center and its
staff from all liabilities while I am staying at the center during the Special
Retreat. In addition, I will fully observe the rules and regulations of tathagata
Meditation Center especially those for the Special Retreat.
______________________________________________ ________________________________
Signature Date
Full name in print _________________________________________________________________
Registration Priority :
Priority is given to yogis who attend the whole retreat. To register, please send in the
application form and a bank check made to payable to TMC. We will confirm your registration
within 2 weeks. We will allow part time yogis to attend if space become available. All
Apart-time registrations will be confirmed 10 days prior to the retreat start date.
NOTE: please include your email address for faster confirmation.
Refund Policy :
* 100% refund if cancelation is recieved 2 weeks prior to the retreat start date.
there will be no partial refund after this date.
* No partial refund for late arrival or early departure.