APPLICATION FOR MEDITATION WORKSHOP AT
Wat Mongkolratanaram, Tampa, FL.
Date ............/................/....................
1. First Name ................ ...............................
Last Name ................................................
Age range 10-19 20-30 31-40 41-50 51-60 61 - up
2. Gender ........... Male .......... Female
3.Address ...............................................................................................................
City..............................................State...............Zip code.................
Tel.( )..............................................
E-mail:............................................
4. Main language..................................
Other fluent languages .......................................
5. How did you learn about this
MEDITATION WORKSHOP? ..............................................
6. Have you had any previous experiences with meditation practices? .........Yes .........No
If yes, please give details: TEACHER/ MASTER/ PLACE
1. ......................................................................How long?..................................
2. ......................................................................How long?.................................
3. ......................................................................How long?.................................
7. In case of emergency, please provide your family/friend's name and telephone number
1. Name .................................................Telephone .............................................
2. Name .................................................Telephone .............................................
I acknowledge that I have carefully read and understood the meditation workshop guidelines. I agree to abide by all the rules and regulations for the duration of the practice. I hereby certify that the above information is true to the best of my knowledge. I further hereby waive and release, indemnify, hold harmless and forever discharge Wat Mongkolratanaram, and its agents and officers from all claims and expenses of every kind and nature, whether known or unknown, arising from or anyway related to my participation in any of activities conducted on the premise of Wat Mongkolratanaram.
Signature.........................................................
Date ........../........./............