(Confidential) Receipt No......
= 25
THE ART OF LIVING
VYAKTI VIKAS KENDRA (INDIA) fesse mes
ART OF LIVING Part-I Application Form vessron
(Please wie CLEARLY and n BLOCK LETTERS) suv photos
[ ]Male [ ] Female
(Mobile)
. Date of Birth
. Specialisation ...
().
e-mail . so AGE esse
Profession...
1. Are you experiencing any of the following health conditions ?
[ ]Asthma [1 Epilepsy [_ ] High Blood Pressure [ ] Heart Condition
[ 1 Back Pain [1 Pregnancy [_] Schizophrenia [ ] Tuberculosis
Others (Please specify)
2. Are you currently taking any prescribed medication ?
[1 Yes [ 1No Ifyes, please explain...
3. Have you ever undergone Psychiatric Treatment ?
[1 Yes [ ].No tyes, please explain.......
4. Please list any other programme in the field of self-development you have participated in/taught yourself ?
5. How did you find out about "The Art of Living" course ?
Declaration
| am participating in “THE ART OF LIVING" programme of my own will and | take full responsibilty for participating inthis programme.
| release Vyakti Vikas Kendra India (Charitable Trust), all organizers, co-ordinators and assistanis in this programme from any alleged
‘adverse affect whatsoever and waive allright to compensation. | dectare that, | am physically and mentally able to partcpate in this
programme. | wil not teach any ofthe techniques of the course unless | have been fully personally trained by SRI SRI RAVI SHANKAR JI.
Date Course Date Venue . Sig.
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This is a Pre-registration Acknowledgement. Official Receipt for this payment would be issued during the course.
Received the sum of Rs. From Smt/Sh.
being the contribution for The “Art of Living Part” Course to be conducted by ....
for the period ...
foe LO sn sow At the VENUE
Visit us at : www.artofliving.org