PLEASE TYPE OR PRINT CLEARLY.

Please indicate the Retreat and dates you will come to Samadhi?
Name of Retreat program _______________________________________
Dates of arrival____________________Departure____________________

Name________________________________________________________
Address______________________________________________________
City_____________________________State/Province_________________
Country__________________________ZIP__________________________
Passport Number ____________________________Expiration date ____________

Day telephone - ( )___________________________
Evening telephone – ( )________________________
Mobile/Cell – ( )_____________________________
FAX – ( )______________________________________
Email___________________________________________

Male_____ Female______ Age _________(optional)

Do you snore? YES____ NO_____

Please indicate any special needs or physical disabilities to assist in assigning your room:
_______________________________________________________________________.

Please indicate how well you understand and speak English:
VERY LITTLE_________ MODERATELY_________ FLUENTLY__________

What is your native language?______________________________

Can you read signs in English? YES ____ NO____ or Czech? YES____ NO_____

What is your meditation practice?_______________________________________________

Have you been to other Vipassana Meditation retreats? YES____ NO____
Where?___________________________________________________
When?____________________________________________________
Teacher’s name?____________________________________________

Have you been to Samadhi Retreat Center before? YES_____ NO_____
Samadhi Center is a smoke free environment. If you have difficulty with this, let us know.

Please mail this form along with your deposit