MBMC Monthly 1-Day Meditation Retreat

Name 姓名*

Gender 性别*

Mobile No 手机号码*

Eg. +(60)11-1111111

Email 电邮*

example@example.com

Age 年龄*

Nationality 国籍*

Please edit field if you are not Malaysian

State 州属*

Country 国家*

Please edit the field if your country is not Malaysia

Meditation Date*

Are you a muslim 您是回教徒吗?*

Yes 是No 不是

We regret to inform that Muslim is prohibited from attending this retreat. With sincere apology, your kind understanding is very much appreciated.

Please state your training in Satipatthana Vipassana Meditation 您的智慧禅学习程度:*

Beginner 初学Experienced Yogi 有经验

Is there any past or present history of mental disorder or illness such a s panic attack, anxiety, schizophrenia or manic-depression 您有精神障碍或疾病(如惊恐发作、焦虑、精神分裂症或躁狂抑郁症)?*

Yes 有No 没有

Does your family members e.q. grandparents, parents, brothers, sisters, uncle, aunt etc. has any history of past or present of the illness as the above 您的家庭成员如祖父母、父母、兄弟姐妹、叔叔阿姨有没有以上的病例?*

Yes 有No 没有

Do you suffer from any contagious diseases like TB and Hepatitis or from any illness that requires constant treatment like advances diabetes, HIV or AIDS 您是否患有任何传染性疾病，例如结核病和肝炎，或任何需要持续治疗的疾病，例如晚期糖尿病、艾滋病毒或艾滋病 ?*

Yes 有No 没有

Have you fully vaccinated for Covid-19 你完成Covid-19疫苗接种?*

Yes 是No 不是

We are sorry that only fully vaccinated participant is allowed to attend the retreat!