Seva Program Application

First Name

Last Name

Phone

Email

Address

Address Line 2

City

State/ Province / Region

Zip / Postal Code

Country

Course Option

Two or More Weeks, Continuous

Two Weeks, Not Continuous

Four or More Weekends

Age

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relation

Do you have health insurance?

Yes No

Do you have any medical conditions that will limit your ability to assist in any projects?

Yes No

Are you taking any prescribed medications?

Yes No

Have you had any mental or emotional conditions that required professional help?

Yes No

Any history of addiction?

Yes No

Do you have any diet restrictions or eating habits we should know about?

Yes No

Do you practice the Surya Ram Meditation or Transcendental Meditation?

Yes

No

Work history, hobbies, skills, and interests:

Why are you interested in the Seva Program?

When was your last visit to Mount Soma?

Name (as signature):

Today's Date