Application Form

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Thank you for taking an interest in the teachings of His Eminence the 7th Dzogchen Rinpoche, Jigme Losel Wangpo. Dzogchen Rinpoche is the holder of the 400-year-old lineage of Dzogchen and due to the precious nature of these teachings, it is important for Rinpoche to have a clear view of your spiritual history.

Please complete all sections of this application form before submitting.

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Personal Details

First Name:
Last Name:
Occupation:
Date of Birth:
/ /
Age:
Sex:
Male Female
Address:
Town / Suburb:
County / State:
Postcode / Zip:
Country:
Home Telephone:
Mobile Phone:
Email:

Photo

Please upload a standard passport photo of yourself.

The file must be one of the following formats - jpg, jpeg or png.
The file must not be larger than 500kbs.

Emergency Contact

Name:
Relationship:
Home Telephone:
Mobile Phone:

Spiritual Details

What Teachings and retreats have you attended with H.E. Dzogchen Rinpoche?

Are you presently doing any spiritual practices? If so, which?

Other Details

The following information is helpful for the Seminar Coordinators to know in case of a medical situation:

Do you have any health conditions that might come up during your participation?

1. Allergies? NO YES

If yes, please specify:

2. Cardiovascular / cardiac condition? NO YES

If yes, please specify:

3. Respiratory condition? NO YES

If yes, please specify:

4. Psychiatric or neurological illness? NO YES

If yes, please specify:

5. Other past or current illnesses? NO YES

If yes, please specify:

6. Do you have any special needs that you would like us to know about? NO YES

If yes, please specify:

Declaration

All information given by you on this application form is regarded as strictly private and confidential within Gyalwa Dzogchenpa and will not be distributed to any other persons or organisations.

We advise that you take out medical and any other relevant insurance for the duration of the retreat. Any medication prescribed by your doctor should be continued as prescribed, throughout the retreat. Applicants with a past history of psychiatric illness or who are receiving psychiatric treatment at present are required to consult their psychiatrist prior to applying for the retreat.

Dzogchen Monastery cannot accept responsibility for personal accidents, injuries, illnesses, exacerbation of existing medical conditions or loss/damage to your personal property during these events.

I have understood the above and confirm that all information provided on this form is true and correct.