VIPASSANA APPLICATION FORM

As taught by S.N. Goenka in the tradition of Sayagyi U Ba Khin

Padhana : 10-DaySpecial : 2023-11-15 Ford, Aaron [Old M Sit]

COURSE
Course Type Special 10-Day
Dates 15 November, 2023 - 26 November, 2023
Location padhana / Dhamma Padhāna
Instruction Language(s) English

APPLICANT TYPE
Have you completed a 10-day course with S.N. Yes
Goenka or any of his assistant teachers?
Please choose what you are applying to do: Attend the course
Select Gender Male
Country or Region of residence Germany
By checking the box below, I acknowledge and agree that any and all information provided in this application for
acceptance into a Vipassana Meditation course, or otherwise provided by me to the Vipassana organizations, may be used
by the Vipassana organizations for their purposes consistent with their Privacy Policies as amended from time to time.
Yes, I accept the terms of the Privacy Policy and the Yes
other terms of submission of this application form.

COURSE REQUIREMENTS
Must be a serious old student who is committed to this technique.
Must have sat at least five 10-Day courses with Goenkaji or one of his assistant teachers.
Must have sat at least one Satipatthana Sutta Course.
Must have served at least one 10-Day course.
Maintenance of daily practice of two hours per day for at least 2 years.
Abstaining from killing, sexual misconduct, intoxicants and keeping other precepts to the best of one's ability for one year
minimum.
Spouse must be supportive of partner sitting long course.
Assistant Teacher who knows you well: Mr. Mario Weippert
Did you find the name of the Assistant Teacher who Yes
knows you well?
Recommending AT Not Found Info Mario Weippert , Germany, Bavaria, Dhamma Dvara

APPLICANT PROFILE INFORMATION

Given / First name in English Aaron
Surname / Family / Last name in English Ford
Age 40
Date of birth 1983-8-11
Occupation Carpenter
Address Campingplatz 1
City Limbach
State or Province Baden-Württemberg
Zip / Postal / Pin Code 74838
Country or Region of residence Germany
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Country or Region of Birth United States

Primary Language English
Please use these descriptions to select the option that best describes how well you understand EnglishExpert I can listen to
the evening discourse and instructions in English.Intermediate I have to listen to the evening discourse in my primary
language but I can understand the instructions in English.Basic I have to listen to the evening discourse and the instructions
in my primary language but I can converse with the teacher in English.Very Basic or None I have to listen to the evening
discourse and instructions in my primary language. I also need to converse with the teacher in my primary language.
How well do you speak and understand English? English: Expert
Other languages you know well: German: Expert
Email Address aaronoford@yahoo.com
Home phone +49 176 39204926
Mobile phone +49 176 39204926
Work phone
Please list someone other than yourself who may be contacted in an emergency.
Emergency Contact Name Ilu
Emergency Contact Phone +44 7392 389356
Emergency Contact Relationship partner
Are you an Assistant Teacher? No
Upload Your Picture:

PRACTICE DETAILS
Are you committed fully and exclusively to the Yes
practice of Vipassana meditation as taught by S.N.
Goenka and his authorised assistant teachers?
In the past two years have you been involved Yes
exclusively with Vipassana meditation as taught by
S.N.Goenka and his authorised assistant teachers,
without going to any other spiritual / meditation
teachers or trying other meditation techniques or so
called energy based healing techniques e.g. Reiki, Qi
Qong, Pranic healing?
Regular daily practice of Vipassana meditation is 2
defined as two one-hour sittings (morning and
evening) each day.

For how many years have you been practicing

Vipassana regularly (i.e. two one-hour sittings daily)?
Please Give Details: For the past few years I have been practicing two hours daily
Vipassana meditation.
During the past year, have you maintained the Five Yes
Precepts as described above without breaking them in
any major way?
During the past year have you abstained from all Yes
alcohol, drugs and intoxicants, i.e. have you not used
any of them at all?
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 Padhana : 10-DaySpecial : 2023-11-15 Ford, Aaron [Old M Sit]

During the past year have you abstained from sexual Yes
misconduct as described above?

PREVIOUS COURSE DETAILS

Please provide us with the details about courses you have both sat and served. If you do not remember the dates, please
use approximate dates. If you do not remember the location or teacher's name(s), please write 'unknown'.
Details of your first 10-day course:
Date of first course (month and year) 2006/4
Location of first course Dhamma Bhummi
Teacher's name(s) for first course sat unknown
Details of your most recent full-time course (10-Day, Satipatthana Sutta, or Long Course); completed as a student:
- type of course 10-Day
Date of last course (month and year) 2023/4
Location of last course Dhamma Pallava
Teacher's name(s) for last course sat: Udo Marquat
Details of your most recent long course completed as a student:
- type of course
- date of course (year and month)
- location of course
- Teachers name(s)
Number of full-time courses completed as student (teacher-led only): Enter '0' if you have not completed the specified
course type.
10-Day Courses 18
Satipatthana Sutta Courses 4
20-Day Courses 0
30-Day Courses 0
45-Day Courses 0
60-Day Courses 0
Number of 10-Day Special courses sat 0
TSC/14-Day Gratitude Courses 0
Duration of TSC/Gratitude Courses 0
10-day courses served 17
Other courses served Children's Courses, LTS

RELATIONSHIP INFORMATION
Are you currently married or in a relationship, or have Yes
you been in the past year?
If yes, is it a life-long committed relationship? Yes
If you are in a life-long committed relationship, please answer the following questions:
Spouse’s name Ilu
Are your relations harmonious? Yes
Is your spouse in favor of you taking the course? Yes
Is your spouse a Vipassana meditator in this Yes
tradition?

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 Padhana : 10-DaySpecial : 2023-11-15 Ford, Aaron [Old M Sit]

Is your spouse practicing any other meditation No

technique besides Vipassana as taught by S.N.
Goenka?

HEALTH AND MEDICAL INFORMATION

Do you now have or have you had in the past any No
mental difficulties?
Do you now have, or have you had, any chronic No
health conditions, injuries, major illnesses, and/or
recent surgeries?
Are you presently taking any medication (prescribed No
or otherwise, e.g. herbal, natural)?

EXPERIENCES DURING COURSES

Have you ever been refused admission to a course or No
had to leave a course for any reason?
Have you ever had difficulties during a course and No
been asked by the conducting teacher to stop/reduce
meditating during the course or at any other time?
Have you had any personal tragedy in the past year, No
e.g. death of a near relative, etc?
Any particular difficulties you tend to encounter No
during courses?

ADDITIONAL INFORMATION
Any special requirements for this course? No
Anything you wish to add to the above information? No
When do you intend to arrive at the center? November 10th
By completing the spaces set forth below with my name, the date and submitting this application, I hereby acknowledge
that I have carefully read and understood the Code of Discipline for the Vipassana Meditation course for which I am
applying. I agree to stay on the course site and to abide by all the rules and regulations for the duration of the course. I
realize that a Vipassana Meditation course is a serious undertaking that will require my full mental and physical health and
I affirm that I am fit to participate in it. I hereby certify that the above information is true and correct to the best of my
knowledge.
Name Aaron Ford
Date 2023-8-12

APPLICATION REFERENCE
Display Language English
Course ID 82fd2cec6d?org_id:1768
Application ID OSA--1691857121
Application Reference Code 2874b86f
Review Status Recommending AT Review
Currently assigned to Mr. Mario Weippert

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