MEDICAL CONDITION
We request the following information to help us determine whether or not participation in a retreat will aggravate a serious medical condition, endanger a participant's health, or disrupt the functioning of a retreat. Please assist us by providing complete and current information on all applicable categories. The information provided will be kept strictly confidential to protect the applicant's privacy.
If you have had serious back or leg ailments, symptoms of headache, dizziness, palpitation, or shortness of breath due to meditation, high or low blood pressure, heart problem, major surgery, allergy, infectious disease, or if you have been treated for serious emotional or psychological symptoms, please briefly state the nature of each problem and the current condition: