(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. pom 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