Mount Soma Seva Program Application

Thank you for your interest in the Mount Soma Seva Course!

Please fill out the form below and we will contact you as soon as possible.

Note: Applicants must be 18 years or older. Seva Course participants will be in ashram dormitory housing and will be eating a vegetarian diet. One application per person.

Name*

First Last

Email*

Phone*

Address*

Street 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

Planned Start Date*

Planned End Date*

Dates of First Week*

Dates of Second Week*

Dates of the Weekends*

Age*

Emergency Contact Name*

First Last

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

Please list medical condition(s)*

Are you taking any prescribed medications?*

Yes
No

Please list prescribed medication(s)*

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

Yes
No

Please list mental/emotional condition(s)*

Any history of addiction?*

Yes
No

Please describe addiction history.*

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

Yes
No

Please describe diet restrictions/eating habits.*

We suggest 2 weeks of twice daily Surya Ram Meditation or TM prior to the Seva Course.

Do you practice the Surya Ram Meditation or TM?*

Yes
No

Work history, hobbies, skills, and interests*

Name (as signature)*

Today's Date*

Captcha

Seva Course Application