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.