Retreat Online Application Form

Meditation Retreat Application Form

Please complete and submit your application online using below form.

Personal Details

Please fill in your personal details below.

1. Full Name (in block letters)

2. Gender

3. Nationality

4. Date of Birth

5. Religion

6. Occupation

7. Permanent Address

8. Telephone

9. Email

Emergency Contact

10. Contact details of a close relative or friend who can be contacted in case of an emergency:

Name

Relationship

Address

Telephone

Type of Meditation Retreat

Please select the retreat type you are applying for.

11. What type of meditation retreat are you applying for?

Long Retreat – Summer (July/August)

Long Retreat – Winter (December/January)

Individual Short Retreat

Please state your intended period of stay.

Note: Individual short retreats will need to be agreed by the resident Monk and Trustees.

Important Notice: Intensive long meditation retreats may not be suitable for those with mental health or physical difficulties affecting mobility and walking.

Previous Meditation Experience

12. Please provide details of your previous meditation experience.

Name of teacher

Type of meditation technique/tradition

Name of centre/monastery

Duration of practice

Have you previously practised Mahasi Dhamma meditation?

Yes

Medical or Psychological Information

This information is kept strictly confidential.

13. Are there any medical or psychological conditions that you feel are important for us to know?

Yes

Please provide further details:

Please tick any that apply to you:

I am taking medication for a medical condition or mental health problem.

I need aids for walking or mobility, for example splints.

Dietary Requirements

Please let us know your dietary needs.

14. What are your dietary requirements?

Vegetarian

Non-vegetarian

Special diet

Other

Please provide details of your dietary requirements:

How Did You Hear About Us?

Help us understand how you found our centre.

Please specify:

Declaration

Please read and accept the declaration below.

"I hereby declare that all the information given above is true and that I have not left out any important information. I undertake to abide strictly by the rules of Panditarama Saraniya Dhamma, practise diligently and follow the instructions of the meditation teacher. I understand that Mahasi Dhamma Fellowship will not be responsible in the event of any physical, mental or psychological injury incurred during the entire period of my stay at Saraniya Dhamma Meditation Centre. The rules include observance of the Eight Precepts, such as abstention from taking food after midday, alcohol, drugs (except prescription medication) and smoking."

I confirm that the information I have provided is true and complete, and I agree to abide by the retreat rules and follow the instructions of the meditation teacher.