Tushita Meditation Centre

MEDICINE BUDDHA RETREAT REGISTRATION FORM

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

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 the retreat carefully?	Yes No
Do you agree to attend all sessions of the Retreat and keep the discipline of the Retreat (including keeping silence, not leaving Tushita until the Retreat ends)?	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 taken the Bodhisattva Vows? When?	Yes NoWhen
Have you taken the Eight Mahayana Precepts before?	Yes No
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.
Have you received the Medicine Buddha Initiation?	Yes No
If no, have you taken other tantric initiations before? Which ones?
Have you been advised by a lama or teacher to do this particular retreat?	Yes No Teacher:
Do you have a commitment to fulfill? If yes, what is your commitment?	Yes No Commitment:
Why do you want to do this retreat?
COMMENTS

MAY ALL BEINGS BE HAPPY!

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