California Vipassana Center — Dhamma Mahāvana

P.O. Box 1167, North Fork, CA 93643 — (559) 877-4386 ext. 1; Fax (559) 877-4387
registration-followup@mahavana.dhamma.org — www.mahavana.dhamma.org

DIABETES QUESTIONNAIRE

Name: __________________________________ Course dates: ______________ to ______________

We can only accept applicants who are medically stable - in other words, your glucose (sugar) levels must be
reasonably well controlled.

Are your glucose (sugar) levels reasonably well controlled? Yes____ No____

Do you use a glucometer to test your blood daily? Yes____ No____

If you are unsure about your glucose control, please discuss with your health care provider to determine if
your diabetes is well managed and if you are medically stable for a course.

If you are on insulin:

Are you able to adjust your insulin safely given the differences in diet, schedule and activity level on the course?

Yes ____ No____

If you are on insulin or think you may need insulin, we require a physician's note stating that you are
medically stable for a course. Please have your doctor see the attached “Course Timetable” document and
“Sample Course Menu” document so they can determine how it will affect your glucose control.

How many snacks do you need per day? (Please specify what type of snack and the time of day you require
them). Note that we supply all students who have diabetes with an evening meal and a bedtime snack.

Do you have any other special dietary needs?

We suggest that you check your sugars more often during the course (as per your doctor’s
recommendations) due to the differences in diet, activity, and schedule as compared to your usual daily
routine (Please see the attached “Course Timetable” document and “Sample Course Menu” document to
familiarize yourself with the schedule and diet.)

It is our recommendation that you bring glucose tablets with you in case your glucose level drops too low
and/or you experience symptoms of hypoglycemia.
PLEASE READ AND SIGN THE FOLLOWING STATEMENT:

I hereby confirm that I have read and understood the above information and have answered all questions
completely and honestly, and have not withheld any information.

I give my consent for release of the any of the above information to medical personnel in the event of a medical
emergency. This consent goes into effect on ________________ and expires on ________________ at the time of
departure from the course site.

__________________________________________________________________________________________
Signature Name Date

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Thank you for taking the time to provide us with this valuable information in the interests of your safety.

Kind Regards,
The Registration Committee

California Vipassana Center

P.O. Box 1167
North Fork, CA 93643
Fax: (559) 877-4387
registration-followup@mahavana.dhamma.org
 California Vipassana Center — Dhamma Mahāvana
P.O. Box 1167, North Fork, CA 93643 — (559) 877-4386 ext. 1; Fax (559) 877-4387
registration-followup@mahavana.dhamma.org — www.mahavana.dhamma.org

Terms and Conditions of Admission to a Vipassana Meditation Course

PLEASE READ AND SIGN THE FOLLOWING STATEMENTS:

All students must stay at the course site following the rules and regulations for the duration of
the entire ten-day course unless given specific permission by the teacher to leave.

The prospective student of this technique of Vipassana meditation should understand the
seriousness of the course. Vipassana aims to purify the mind of deep-seated impurities such as
fear, anger, greed, aversion, etc. by bringing the mind into a state of perfect balance whereby
these impurities are objectively observed and uprooted. Thus it is necessary that a prospective
student be reasonably healthy both physically and mentally. Persons who have a previous history
of a severe mental or physical disorder should not attempt the course without the prior advice
and consultation of their physician and / or psychiatrist to ensure that they are indeed fit to
undergo this training.

By completing the application to participate in a ten-day Vipassana meditation course, the

applicant acknowledges the foregoing warning and in consideration of being permitted to
participate in the course knowingly grants to the organizers of this course, the Sayagyi U Ba
Khin Vipassana Trust and its associated organizations including Vipassana Center and teachers,
a complete, total and unequivocal release of any and all liability for any adverse mental or
physical consequences which may result directly or indirectly from such participation.

Signature Print your name here Date

Thank you for taking the time to provide us with this valuable information in the interest of your
safety.

Sincerely,

The Registration Committee