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Registration form

Please select the course or courses (2010) you want to participate in:

Accomodation:

I would like a single bedroom
I would like to share a double bedroom
I prefer a single bedroom, but will share a double if no single is avalaible
No accomodation is needed for this program

Mode of payment:

I deposit the fee of the course to giro 4908181 of the Noorder Poort in Wapserveen
I deposit the fee to the Raiffeisenbank Erkrath,
    Konto- Nr. 408115019, BLZ: 37069521
This is a free program

 Male Female
First name:
Last name:
Buddhist name:
Date of birth:
Profession:
Address:
Postal code:
City:
Country:
Telephone:
Fax:
E-mail:

I speak DutchYes No
I speak GermanYes No
I speak EnglishYes No
I speak SpanishYes No

If you are new to the Noorder Poort, please tell us something about your experience with meditation:

If you follow a diet on doctors' prescription, you can tell us here:

Further remarks:

If you have completed the form, please click Send and after that OK or Send.