Registration Form Full Name Mobile No. Email Full Address State Andhra Pradesh Arunachal Pradesh Assam Bihar Chhattisgarh Goa Gujarat Haryana Himachal Pradesh Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal Pin No. Have you had any previous experience with meditation techniques, therapies or healing practices? Yes No If yes, please give details Do you teach or practice these techniques/therapies on others? Yes No If yes, please give details How did you learn about Navaprerona, or who introduced you to this course? Do you have any physical health problems, medical conditions or diseases? If yes, please give details (dates, symptoms, duration, treatment, and present condition). Yes No For women applicants: Please indicate whether you are pregnant. Yes No 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, and present condition). Yes No Are you now taking, or have you taken within the past two years, any alcohol or drugs (such as marijuana, amphetamines, barbiturates, cocaine, heroin, or other intoxicants)? If yes, please give details (dates, types, amounts, additions, treatment, and present use). Yes No Are you now taking, or have you taken within the past two years, any prescribed medication? If yes, please give details (dates, types, dosage, and present use). Yes No I acknowledge that I have carefully read and understood the NAVAPRERONA, Introduction to the Technique and Code of Discipline for Meditation Courses. 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 Navaprerona 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 to the best of my knowledge. In addition, I hereby consent to the storage and handling on a computer or otherwise of my above stated personally identifiable information in accordance with the Privacy Policy of the facility at which the course for which I am applying is being held. Submit
