MLA General Class Sign Up Form

Class to Sign up for:
Please indicate days/hours to attend if applicable:
Name (Last, First Middle):
E-mail Address:
All fields are required for acceptance.

* You may skip if same info already submitted to MLA. *
Gender: Male Female
Age (Please select one) :
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 and any other MLA events.

  You can submit only if you agree to the terms.

I agree
  The registeration will be confirmed within 10 days.
Contact: (Email), or (Tel) (408) 505-5190 for more information.