The 3rd 21-Days Chan Retreat Online Registration Form (For Laypersons only)

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【Part 1】：Remittance Slip

1.01 Course Option:

1.02 Please upload the【remittance slip】

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1.03 Please upload a【headshot】:

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【Part 2】：Personal Info

2.01 First Name

2.02 Last Name

2.03 Day of Birth

2.04 Gender

2.05 Mailing Address (House Number, Street Name, Residential Area, Postcode, County / City)

2.06 States / Provinces

2.07 Country

2.08 Mobile Number

2.09 NRIC / Passport

2.10 Email Address

2.11 Occupation / Major

2.12 Company / Educational Institution

【Part 3】：Buddhist Learning Journey

3.01 In which year did you begin study Buddhism?

3.02 Dharma Title

3.03 Referring Master for Refuge Certification

3.04 Have you ever learned seated meditation?

3.05 If so, who was your mentor?

3.06 Have you ever participated in an intensive course organized by the “Hui Deng Meditation Group”?

3.07 Please specify the year(s) you previously participated (max. 30 words).

3.08 Total Number of Attendances

3.09 Do you practice regularly on weekdays?

3.10 If applicable, how do you schedule your practice time?

3.11 Which Buddhist organization are you currently active in?

3.12 What position do you hold in the organization?

3.13 Which Buddhist books have had the greatest influence or inspiration on you?

3.14 Which Buddhist courses and group practice activities have you participated in?

3.15 What is your motivation and objective for participating in the intensive Chan meditation retreat?

3.16 Briefly describe your reflections after studying the Dharma and practicing seated meditation

【Part 4】：Health Status

4.01 Health: Do you have any physical illnesses, eg. diabetes, heart disease or others?

4.02 Psychological: Do you have any emotional/psychological illnesses, e.g. anxiety, depression?

4.03 Are you currently on any medications? If any, please state the type(s) of medication and intake routine(s).

4.04 If necessary, Please attach an enclosed letter to our Retreat Master

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【Part 5】：Info of Emergency Contact

5.01 Emergency contact

5.02 Emergency contact number

5.03 Relationship to Emergency Contact

【Part 6】：Signature & Declaration

6.01 I declare that the information provided is accurate and complete.

6.02 I commit to observing all course rules during my stay.

6.03 I am solely responsible for my own physical and mental health issues

6.04 Date of Signature

【Part 7】：Please fill in the CAPTCHA

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