Thailand Vipassana Insight Meditation Center Wat Phradhatu Sri Chom Tong Woravihara

Application form for meditators

● Personal Particulars

Full name:

Nationality:

Date of Birth:

Tag

Monat

Jahr

Passport Number:

Purpose of visit to Thailand:

Present Address:

Education:

Occupation:

Thai Mobile/ WhatsApp:

Email address:

● Experiences

Experience(s) at Wat Chom Tong:

Source of Information about Wat Chom Tong (please specify):

Experiences on other types of meditation practice:

Yes

No

Reason to practice Vipassana Insight Meditation:

Arrival Date

Departure Date:

Total:

● Medical and Health Profile

History of Chronic Physical/ Mental illnesses:

Yes

No

History of alcohol or drugs abuses/addictions:

Yes

No

Are you currently taking any medication? If so, please state:

Yes

No

Drug Allergy:

Yes

No

Are you currently taking any alcohol or drugs?

Yes

No

● In Case of Emergency, please contact:

Name:

Relationship:

Mobile number:

"I hereby certify that the above information is correct and true. I will not hold Wat Phradhatu Sri Chom Tong Woravihara or any of the staff responsible for any mishaps or damages that occur while I'm visiting. I promise to abide by all rules and regulations of the monastery, as well as any guidance offered by a designated monk meditation instructor and/or any relevant reservation office staffs."

I accept the terms and conditions.

Food

Meat

Vegetarian

Gender

Male

Female

Height/Weight