P.O.

Box 941
Onalaska, WA 98570
info@prison.dhamma.org

PRISON DHAMMA SERVICE FORM

I would like to serve on a Vipassana course in prison

Minimum requirements for this service: 3 courses sat, 3 courses served, daily practice for the past 2
years. This is not necessarily an application for a particular course.

I would like to serve the Vipassana Prison Trust in some other capacity.
For example: fund raising, website development, IT. Minimum requirements for this service: Must
be an old student who is maintaining a daily practice.

Please complete this form and return it to the above address. Please answer all questions fully.
This information will be kept for one year and be kept strictly confidential.

Course Dates (If known) From:       To:      

Location (If known):      

First Name (Given): Name (Family):

Phones
Cell: Home: Work: FAX:      

E-mail Addresses:

Street Address

City State/Province:

Age: Gender: Date of Birth: Year Month Date

Occupation:

Do you speak and understand English very well?

Do you speak any other languages? If Yes, which, and how fluently?      

Please give details of your courses with S.N. Goenka or his Assistant Teachers

Date Location Teacher/s

Page 1 of 3
First Course

Most Recent Course

Total Number of 10-Day Courses Sat Full-Time      

Courses Served Full Time            

Other Courses Sat (specify)            

Please give the name of a teacher or AT with whom you have served a course, and the date and
location of the course on which you served

AT: Course Date: Course Location:

1. Have you maintained your practice of Vipassana meditation since your last course?
Please give details (how much time daily, etc

2. Have you practiced any other meditation techniques (including other types of Vipassana) or
therapeutic or healing techniques since your last course with S.N. Goenka or his assistant
teachers?
● If Yes, please give details.      

3. Have you maintained the five precepts since your last course?
● If No, please explain.      

4. Do you currently drink alcohol or take drugs, or have you taken any alcohol or drugs (such as
marijuana, amphetamines, barbiturates, cocaine, heroin, or other intoxicants) within the past 2
years?
● If yes, please give details (dates, types, amounts, present use).      

If you are not applying to serve inside a prison, please go to question 14.

5. Do you have any physical health problems, medical conditions or diseases?

● If Yes, please give details (dates, symptoms, duration, treatment, present condition).      

6. Do you have, or have you ever had, any mental health problems such as significant depression or
anxiety, panic attacks, manic depression, schizophrenia, etc.?
● If Yes, please give details (dates, symptoms, duration, hospitalization, treatment, present
condition).

Page 2 of 3
7. Are you now taking, or have you taken within the past 2 years, any prescribed medication?
● If Yes, please give details.      

8. Have you ever worked or volunteered in a correctional facility?

● If Yes, please give details.      

9. Have you ever been arrested, convicted or incarcerated?

● If Yes, please give details

10. What are difficulties you have had when serving on courses, or that you might expect to encounter
when serving on a prison course?

11. Why do you want to serve on a Vipassana prison course? I think it would be challenging and very
good for my practice and also deeply rewarding

12. Do you have health insurance? If not, could you get temporary health coverage for the time you are
serving on a prison course?

13. Please name an Assistant Teacher who knows you well for a referral:

I acknowledge that I have carefully read and understood the Code of Conduct for Dhamma
Workers, and I agree to abide by all the rules and regulations while I am at the prison course. I
realize that serving on a Vipassana meditation course in a prison is an especially serious
undertaking that will require my full mental and physical health.

I affirm that I believe I am fit to participate in it.

14. Other than directly participating in a prison course as a dhamma worker, what other interests,
skills, or abilities would you like to offer the Vipassana Prison Program?

I hereby certify that the above information is true to the best of my knowledge.

Signature: Date:

Page 3 of 3