法域喜马拉雅禅修报名表格 Dhamma Earth Himalaya Dhampus Nepal Retreat Application

您好，请注意佛护尊者禅修营已额满，您所报名的是候补名单。 Greetings, please be noted that Bhante Buddharakkhitta Meditation Retreat is full, you are register for waiting list now.

I'm 我是*

姓名 Name*

依护照/IC as per Passport/IC

法名 Dhamma Name

戒师 Preceptor Name (Upajjhāya)*

依护照/IC as per Passport/IC

出家年份 Ordain Year

雨安居年份 Vassa

出生日期 Date of Birth*

禅修时段 Retreat Period*

June 1, 2025 - July 1, 2025 (2025年6月1日 - 7月1日) - 佛护尊者

Please refer to the poster for date fly to Kathmandu. 飞往加德满都日期请参考海报。

国籍 Nationality

马来西亚人 Malaysian

非马来西亚人 Non-Malaysian

国籍 Nationality *

护照号码 Passport No*

护照截止日期 Passport Expiry Date*

签证截止日期 Visa Expiry Date

性别 Gender*

身份证号码 NRIC No *

宗教 Religion*

电邮地址 Email address*

电话 Contact Number*

Eg: +6010-1234567

微信号 WeChat ID

Eg: de_himalaya

仅供中国贤友 Only for Chinese devotees

戒师名 Upajjhaya’s Name*

出家日期 Ordination Date*

出家地点 Place of Ordination*

专业领域 Area of Profession

职业 Occupation*

通讯地址 Correspondence Address*

州/省 State/Province

市 City*

州 State*

邮政编码 Postcode*

国家 Country*

个人照片上载 Photo Upload*

正面照 Front Portrait Photo

戒牒照片上载（出家证） Ordain Certification Upload

正面照 Front Portrait Photo

紧急联络人姓名 1 Emergency Contact Name 1*

关系 1 Relationship 1

联络电话 1 Contact Number 1*

紧急联络人姓名 2 Emergency Contact Name 2

关系 2 Relationship 2

联络电话 2 Contact Number 2

禅修方法 Type of Meditation Practice*

禅修老师 Meditation Teacher

你是否曾经在任何法域道场（或兜率天修行林）修行过？Have you practiced at any Dhamma Earth monastery or Tusita Hermitage in the past?

是 Yes

否 No

如果有，请简述何时，多久与向哪一位禅师学习。 If so, please give a brief description of when, the duration, and under which Teacher(s) guidance.

你是否有较严重的疾病？Do you have any significant physical health ailments or conditions? *

是 Yes

否 No

如果有，请告知你现在的状况和药物，以及病史及治疗状况。 If so, please give details of your present condition / medication, the condition’s history and treatments *

你现在是否有任何精神方面的疾患，如忧郁、焦虑、歇息底里或其他？ Do you currently have or in the past had any mental health conditions such as depression, panic attacks, hysteria, etc.? *

是 Yes

否 No

如果有，请告知你现在的状况和药物，以及病史及治疗状况。If so, please give details of your present condition / medication, the condition’s history and treatments *

最近3年以来，你是否有饮酒及服用毒品及任何麻醉品？Have you ever used any alcohol, drugs, or any other intoxicants in the past 3 years? *

是 Yes

否 No

如果有，请告知现在及以前的状况，毒品的类型，是否成瘾，及治疗状况。If so, please give details of present and past usage, types, addictions, treatments, etc. *