Tushita Meditation Centre

INTERMEDIATE COURSE REGISTRATION FORM

This form will be read only by the course teachers and Tushita management. Any information given will be held in strict confidence.

Please state which intermediate course you would like to attend (title and dates).
PERSONAL INFORMATION
Name
Email
Nationality
Country of current residence
Date of birth
Gender	Male Female
Are you an ordained monk or a nun?	Yes No
MENTAL & PHYSICAL HEALTH
Have you lately / presently experiencing severe emotional stress or depression?	Yes No
If yes, please give details.
Are you presently taking any medication?	Yes No
If yes, what for?
Have you ever been in psychiatric care?	Yes No
If so when?
COURSE INFORMATION & DISCIPLINE
Have you read all the information on our website about this course carefully?	Yes No
Do you agree to keep the discipline of the course?	Yes No
PREVIOUS EXPERIENCE
How many years have you been studying and practicing Buddhism? In which tradition?
Have you taken Refuge in the Buddha, Dharma, Sangha? When ?	Yes NoWhen
What Course (Lam Rim) experience do you have? * A one-month Kopan course? * A 10-day Intro course at Tushita or Kopan? * Others? Please explain
Have you ever done a strict practice retreat before (i.e. doing 4 sessions of PRACTICE each day—this does NOT include courses)?	Yes No
If yes, please describe your retreat experience.
Why do you want to do this course?
COMMENTS

MAY ALL BEINGS BE HAPPY!

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