Application Form

Please indicate which retreat you wish to book for. Please note: you may have to adjust dates for retreats longer than one week.

Name of retreat

Dates you wish to attend

Forename

Surname

Address

Town

Region

WalesNorth WestNorth EastYorkshire & the HumberEast MidlandsWest MidlandsEast of EnglandLondonSouth WestSouth EastOther

Post Code

Country
United KingdomAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArmeniaArubaAustraliaAustriaAzerbaijanAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia and HerzegovinaBotswanaBouvet Island (Bouvetoya)BrazilBritish Indian Ocean Territory (Chagos Archipelago)British Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCanadaCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKazakhstanKenyaKiribatiKoreaKoreaKuwaitKyrgyz RepublicLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Netherlands)Slovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard & Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUnited StatesU.S. Virgin IslandsU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe

Tel. (home)

(weekend/mobile)

Email

Gender
MaleFemaleOther

Age
18 – 2425 – 3435 – 4445 – 5455 – 6465 – 7475 – 8485+

Emergency Contact

Name

Tel.

Have you attended a full week's Mahasi meditation course led by Bh.Bodhidhamma or Noirin Sheahan?

YesNo

Please say with whom and how long ago.

If you have not practised with Bh.Bodhidhamma or Noirin Sheahan, have you practised any form of meditation?

YesNo

Please give some indication of the practises and with whom.

Please note the diet is vegan. You can see the recipes on the Diet link under Retreats tab, so please read these to see if our diet would be suitable for you.

Please note we can usually only deal with common intolerances such as gluten. If your have a dietary allergy or intolerance that you think we might be able to cater for, please tell us below.

Please be specific.

Do you have any physical disabilities we need to be aware of?

Please note that our facilities are not suited for severe disabilities.

YesNo

Please be specific.

Have you a serious medical condition or have you suffered from a mental illness?

YesNo

Have you ever attempted suicide?

What was the mental illness you suffered from?

Are you on medication?

Please email the relevant teacher either to describe your condition or to ask them to phone you.

Bhante Bodhidhammabodhidhamma@satipanya.org.uk
Noirin Sheahannoirinsheahan@gmail.com
Guus Wentguus.went@gmail.com
Carl FooksCarl Fooks

You need to do this as soon as you apply for a course.

All information is strictly confidential.

If, however, you are particularly concerned with confidentiality, it is best to phone. The teacher will give you their phone number once you contact them by email.

If travelling by car, are you able to offer a lift to other retreatants?

YesNo

Do you want come as the Assistant?

As an assistant, we do not expect payment of the deposit or offer a donation because you have kindly offered your time.
And as usual any further dana by you in your gift.

Your commitment is essential, for the course would be very difficult to run without an assistant and may indeed have to be cancelled.

YesNo

New to Satipanya?

Would you like to receive our monthly Newsbyte? This keeps you up to date with events at Satipanya, changes in the Calendar and also has a Tip o' the Day to help with daily practice.

Yes, please subscribe me to the monthly Newsbyte!

If you are coming for the first time , it is helpful for us to know how you came to hear about us

Word of mouthSaw a teacher at a different locationGoogle search/websiteOther