/Retreat #

~
NISSARANA VANAYA RETREAT CENTRE MEETHIRIGALA
Web Site - www.nissarana.lk E-Mail - nissaranavanaya.offce@gmail.com / App. No.

(For offce use only)

APPLICATION FORM FOR RETREATS

NAME OF RETREAT ORGANIZER

_______________________________________________________________________________________________________

DURATION FRO ______________________ TO ________________________ NUMBER OF __________

M DAYS

NAME First ________________________ Last _________________________________________

Name Name

PRESENT MAILING ____________________________________________________________________________________

ADDRESS

CONTACT NUMBERS Mobile _____________________________ Land Line _________________________________

...
/NIC No. / Passport No.

NIC OR PASSPORT
NUMBER
D __ __ M __ __ Y __ __ __ __
DATE OF BIRTH
/ /Male /Female
__________________________________
GENDER VOCATIO
N
- ____________________________________________________________________________________
E-MAIL ADDRESS
?(' ')
HAVE YOU DONE ANY MEDITATION AT NV OR ANY OTHER CENTER BEFORE( If YES please indicate YES NO
which centre and which
year/month?)

/ DETAILS OF NEXT OF KIN IN CASE OF EMERGENCY

NAME First _____________________________ Surnam ______________________________________

Name e

PRESENT
MAILING ____________________________ _____________________________ ____________________________
ADDRESS
Mobile ________________________________ Land Line ____________________________________
CONTACT
NUMBERS
_____________________________ _____________________________ ___________________________
RELATIONSHIP
_____________________________ _____________________________ ___________________________
- ?( ' ' )
E-MAIL ADDRESS
HAVE YOU BEEN RECEIVING TREATMENT FOR ANY PHYSICAL OR MENTAL ILL /YES /NO
HEALTH? ( If yes give a
brief description about your medications )

DATE OF THE LAST RETREAT ________________ NUMBER OF RETREATS ATTENDED DURING THE _______
CURRENT YEAR
AT NISSARANA VANAYA
ATTENDED AT NISSARANA VANAYA
.,..

I do hereby declare that the above-mentoned details are accurate. Im joining this meditaton program voluntarily and being well aware
that neither the teacher nor the management of the Nissarana Vanaya Retreat Center will be held responsible for any unexpected
emergency; especially in case of sudden illness. Furthermore, I agree to abide by the stpulated rules, regulatons and conditons stated by
the Management of the Retreat Centre. I will always comply with these regulatons.

/ Date : ............................................................
.......................................................................................