Wheel of Dhamma Israel Vipassana Meditation Center

Bodhi Leaf

Application for One-Day Old Student Course

One-day courses are for old students who have taken at least one 10-day course
with Mr. S.N. Goenka or his assistant teachers.

*Course Date:  / / Course Location:  

To apply for a place in the course, please complete this form, submit it, and await notification. Please answer all questions fully. This information will be kept strictly confidential.

* First (Given) Name * Last (Family) Name * City
* Phone * E-mail Address:
* Age * Date of Birth: / / * Gender:   Occupation:
* Native language: Other languages that you understand well:

* Have you completed a 10-day course with S.N. Goenka or any of his assistant teachers? No   (New Student) Yes (Old Student)

First Course: * Date / / * Location Teacher(s)
Most Recent Full Course(Sat): * Date / / * Location Teacher(s)
* Total Number of 10-Day Courses Sat Full-Time:

1. * Have you practiced any other meditation techniques (including other types of Vipassana), therapies or healing techniques since your last course with S.N. Goenka or his assistant teachers?   No   Yes
   If yes, please give details.
2. * Do you teach or practice on others?   No   Yes
   If yes, please give details.

Would you be willing to come early to help set-up if needed?   No   Yes
Would you be willing to serve this course should the need arise?   No   Yes

I acknowledge that I have carefully read and understood the Introduction to the Technique and Code of Discipline for Meditation Courses. I agree to stay on the course site and to abide by all the rules and regulations for the duration of the course. I realize that a Vipassana meditation course is a serious undertaking that will require my full mental and physical health and I affirm that I am fit to participate in it. I hereby certify that the above information is true to the best of my knowledge.

* Signature:      Date:

Check here if you are driving and willing to be contacted by other students seeking a ride to the course:
Where are you coming from?