這份資料絕對保密。請先閱讀課程行為規範及報到注意事項
請詳細填寫以下欄位，資料不詳或錯誤將會延誤報名作業，耽誤錄取機會。
Please read The Code of Discipline carefully before applying the course
Please answer all the questions. This information will be kept strictly confidential.
| 課程日期(Applying Course): | 2010/04/10 法工 Dhamma Worker |
| 中文姓名(Chinese Name): | |
| 英文姓名(English Name): | |
| 電子郵箱(Email): | |
| 住宅電話(Home Tel): | () |
| 辦公電話(Office Tel): | () |
| 行動電話(Mobile): | |
| 傳真(Fax): | |
| 年齡(Age): | |
| 性別(Gender): | 男 女 |
| 出生日期(Birth Date): | 月 Month/ 日 Day/ 19 年 Year |
| 住址(Home Addr): | (郵區) |
| 辦公室地址(Office Addr): | (郵區) |
| 職業(Occupation): | |
| 學歷(Highest Education): | |
| 身份證字號或護照號碼(ID or Passport Number): | |
| 您聽得懂英文嗎？Is English Well understood? | 懂 YES
/ 不懂。 NO
如果不懂 ，請說明:If No, please specify 會說(Speak)不會(Don't speak) 國語/普通話/華語 Mandarin 會說(Speak)不會(Don't speak) 福建話/台語 Taiwanese 會說(Speak)不會(Don't speak) 廣東話 Cantonese 其它(請列出) Other, please specify: |
有沒有家庭成員或朋友一起參加今次這一個課程？ Do you have family member or friend participating this course? 有 YES 否 NO
如有，請填寫姓名／關係 if so, please write down his/her name and relationship.
第一次課程 First Course 日期(Date): 地點(Location): 老師(Teacher):
最近一次課程 Most recent Full Course 日期(Date): 地點(Location): 老師(Teacher):
曾參加十日課程次數 : 全程學生 Total number of 10-Day courses: 全程法工 Served Full time
參加過的其他課程(請詳述) Others Courses Sat (Specify):
服務過的其他課程(請詳述) Others Courses Served (Specify):
1.從上次參加葛印卡老師或其助理老師所指導的課程之後，您有沒有練習過其它的靜坐/禪修方法（包括其它內觀法）或心理諮商療程或身心靈修療法?
Have you practiced any other meditation techniques (including other Vipassana techniques) or therapeutic techniques since your last course with S.N. Goenka or his assistant teachers? 有 YES 無 NO
如有，請詳述。 if so, please give details
2.您是否教授靜坐禪修療法或替他人治療?
Are you teaching any other meditation techniques (including other types of Vipassana), therapies or healing ? 有 YES 無 NO
如有，請詳述。 if so, please give details
3.從上次參加十日課程之後，您有無繼續練習葛印卡老師所教之內觀方法?
Have you maintained your practice of Vipassana meditation since your last course? 有 YES 無 NO 請詳述, 如每天幾小時等。 Please give details (how much time, daily, etc.)
4. 從上次課程之後，是否遵守五戒?
Did you try to keep five precept since last course?
有 YES否 NO
5. 如有需要，您可以提早報到?
Can you come early to help with set-up if needed?
可以 YES不可以 NO
6.如果您無法全程參加，請說明到達日期及時間:(Arriving) 離開日期及時間 (Leaving):
If you are not attending the entire course, please give your arrival date and hour:
7.假如您開車來並願意搭載其他學員，請註明:
if you drive and willing to give other student a ride, please specify,
您有沒有任何身體上的健康問題或疾病? 如:糖尿病、心臟病、癲癇症、高血壓，或傳染病如:肝炎、肺結核、傷寒、愛滋病或帶原者，或是其他…。
Do you have any physical health problems, e.g., diabetes, heart disease, epilepsy, high blood pressure, active communicable diseases such as hepatitis, tuberculosis, typhoid, HIV.+, A.I.D.S., etc.? 無 NO 有 YES 。
如有，請詳述（日期，症狀，已病多久、治療情形，現在狀況）。
if yes, please give details(symptoms, their severity, duration, recurrence, treatment).
現在或過去,您有沒有精神(心理)方面的問題>呢？如明顯沮喪或焦燥、惶恐、極度沮喪或人格分裂等?
Do you have or have you ever had any mental health problem, e.g., significant depression or anxiety, panic attacks, manic depression, schizophrenia etc.? 無 NO 有 YES。
如有，請詳述（日期、症狀、已病多久、入院、治療情形、現在狀況）。
If yes, please give details (symptoms, their severity, duration, recurrence, treatment, hospitalization, dates).
您現在或最近兩年內有沒有服用過醫生處方的葯品?
Are your now taking, or have you taken within the past two years, any prescribed medication? 無 NO 有 YES 。
如有，請詳述 (日期，藥名，劑量，目前服用情形) 。
If yes, please give details (types, dosage, frequency and duration of use)
您現在或最近兩年內有沒有服食任何酒類或毒品，如大麻，安非他命，巴比妥鹽，古苛鹼，海洛因，或其他麻醉品等
Are you now taking, or have your taken within the past two years, any drug, e.g., amphetamines, barbiturates, cocaine, heroin, alcohol, or other intoxicants? 無 有 。
如有，請詳述(日期，種類，吸食量，上癮情況，治療方法，目前服用情況) 。
If yes, please give details (types, amounts, frequency and duration of use, treatment).
本人已詳細閱讀且充分了解《內觀簡介及課程的行為規範》小冊中所述的行為規範。本人同意在課程進行期間待在內觀課程地點的範圍之內並遵守所有規定。本人了解內觀課程是一個嚴格的訓練，要接受這個訓練需要具備健全的身心狀況，本人保證自己能夠承擔此一訓練。本人在此聲明，盡我所知，以上所填寫的資料是真實的。
I acknowledge that I have carefully read and understood the Code of Discipline for the Course (in the Introduction to Vipassana Meditation booklet). I agree to stay on the course site and abide by all the rules and regulations for the duration of the course. I realize that a Vipassana course is a serious undertaking that will require my full mental and physical health and I certify that I am fit to undertake it. I hereby certify that the above information is true to the best of my knowledge.
簽名 Sign:
日期 Date: