International Meditation Centre
IN THE TRADITION OF SAYAGYI U BA KHIN
Please first read our Course Guidelines & Course Timetable / 
Lees svp. eerst de Richtlijnen en Dagrooster voor de cursus
COURSE FORM ………Please complete in BLOCK CAPITALS=HOOFDLETTERS 

I wish to attend Meditation Course to be held from:     		to:  
	Surname: 	First Name: 
	Date of Birth: 	Occupation: 
	Male or Female: 	Nationality: 
Do you understand English well? Yes /No:	 If no, what language? 
	Your address (street, nr., postal code, place, country): 	

	Telephone: 	Mobile: 	Email: 

Please give details of someone to contact in case of emergency: 
	Name: 	Telephone: 
	Address: 

1. Have you attended courses in the Sayagyi U Ba Khin / Mother Sayamagyi tradition before? 
	Yes O No O.    If yes, please say when and where was your most recent course 

2. Are you practising any other techniques of meditation? 
	Yes O No O.    If yes, which and for how long have you been practising them? 

3. Are you in good physical and mental health? 
	Yes O No O.    If no, please give details 

4. Are you, or will you be, on any medical treatment at the time of the meditation course? 
	Yes O No O.    If yes, please give details of medication 

5. Do you suffer from any serious food allergies? 
	Yes O No O.    If yes, please give details 

6. Have you had any serious physical or mental illness in the past? Or have you had a significant problem as a result of alcohol or drug abuse? Have you been in psychoanalysis or therapy? 
	Yes O No O.    If so, please explain

7. Have you had a recent crisis in your life?
	Yes O No O.    If yes, please explain 

8. How did you come to know about this centre and the meditation course? Could you please name the magazine, website, friend, poster, etc. from which you learned of the International Meditation Centre. 

All information will be kept strictly confidential. Your name and address will be held on a database only for the despatch of our newsletter. If you do not want to receive a newsletter please indicate that here.
Splatts House, Heddington, Calne, Wiltshire SN11 0PE, England. Tel: +44 1380 850 238 Fax: +44 1380 850 833
Email: imcuk@internationalmeditationcentre.com 	www.internationalmeditationcentre.com
Sayagyi U Ba Khin Memorial Trust (Charities Act 1960 Registration Number 280134)
Ingevuld formulier sturen naar: secretaris@ubakhin.net of Sayagyi U Ba Khin Stichting, Centrumlaan 10, 6869 VE Heveadorp, tel. 026-3332554