MLA Beginners' Class Sign Up Form
 
Date to Attend:
*Name (Last, First Middle):
*E-mail Address:
*fields are required for submission.

* You may skip if same info already submitted to MLA. *
Gender: Male Female
Age:
Address, No. & Street:
Address, State & Zip:
Land phone:
Mobil phone:
Emergency Contact Name:
Emergency Contact Relation:
Emergency Contact Phone#:
Medical conditions, allergies or
physical limitations we should be alerted to?
Brief description of your prior
Vipassana experience if any:

I, the undersigned, hereby certify that the above statements are true and correct to the best of my knowledge. I understand that Mindful Living Alliance is a non-profit organization and the events are organized and conducted for the benefit of meditators like myself. I hereby waive and indemnify MLA and its staff, organizers and volunteers from any and all liabilities during my attendance at this event.
  You can submit only if you agree to the terms.

I agree
 
  The registeration will be confirmed within 10 days.
Contact: (Email) events@mlausa.org, or (Tel) (408) 505-5190