Student Application Form – Male Yogi * Required field 1. Personal particulars Name in Passport/IC * Dhamma Name NRIC No. Nationality * Religion * Date of Birth * (d/m/yyyy, e.g 31/1/1970) Gender Male Female Photo * (passport photo,jpg,max 300KB) For foreigner only Passport No. * Passport Expiry Date * Visa expiry Date Contact details Address * Contact No * Email * Retreat Location Kuching (East Malaysia)Semenyih (West Malaysia)Dhampus** (Nepal) ** For Dhampus, priority will be given to applicants who can attend full session (see dates below) and to key members under ongoing training. Retreat date** from * to ** For Dhampus, retreat dates available are from 12/12/16-8/1/17 ONLY. Remarks 2. Emergency Contact Person First contact Name: * Relationship: * Contact No: * Second contact Name: Relationship: Contact No: 3. Meditation Experience Type of meditation practice : Meditation Teacher: Have you practiced at Tusita Hermitage or Bodhivana Buddhist Hermitage in the past? Yes No If so, please give a brief description of when, the duration, and under which Teacher(s) guidance. 4. Health & Well-Being Do you have any significant physical health ailments or conditions? Yes No If so, please give details of your present condition / medication, the condition’s history and treatments: Do you currently have or in the past had any mental health conditions such as depression, panic attacks, hysteria, etc.?: Yes No If so, please give details of your present condition / medication, the condition’s history and treatments. Have you ever used any alcohol, drugs, or any other intoxicants in the past 3 years? Yes No If so, please give details of present and past usage, types, addictions, treatments, etc. 5. Important Rules and Regulations of Tusita Hermitage The Tusita Sangha Council (Council) Chairs the Management and Administration of the Hermitages Sangha & Sayalay Officers serve on behalf of the Council to carry-out daily administrative duties of the Hermitages Students must respectfully adhere to administrative instructions given by management The Hermitages do not allow self-practitioners; interviews with the Meditation Teacher must be attended Students must take Dhamma instructions from only the approved Meditation Teacher Students should practice with respect, sincerity, diligence, honesty, patience, perseverance and continuous mindfulness throughout their stay at the Hermitages 6. Declaration I hereby declare that: I will respect the Theravada Sangha system, Tusita Sangha Council leadership and administration of the Hermitage. I promise to undergo the Purification of Virtue as outlined in the “Code of Discipline” during my stay. I will respectfully and faithfully go for, receive and apply the Dhamma instructions given by the Meditation Teacher. I have read and clearly understood the “Code of Discipline“ and “Important Rules & Regulations of Tusita Hermitage” and undertake to abide by all such discipline, rules and regulations. I will readily accept any changes and addition of rules pronounced by the Council. I will not give any teaching or involve in the administration of the Hermitages except at the request of the Council. I will be tolerant, forgiving and harmonious in the community. I will keep to the rules of Noble Silence and Non-Communication with Non-Residents (outsiders) except with the specific permission of the Council. I will declare and hand over my mobile phone, computer etc. to the Council’s care throughout my stay in the Hermitages. I will not leave my belongings behind at the Hermitages. Besides my vital belongings (wallet, hand-phone, passport, IC, etc.), I relinquish all items I leave behind by accident to the discretion of the Council. I have completed this Student Application Form honestly, true-heartedly and to the best of my ability. I agree to all terms and conditions of training at the Hermitages Sincerely, Name Date You are required to tick the check box in "6.Declaration' before submitting form.