sahyankan-2013 application form
TRANSCRIPT
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2) mebHetCe& HeÊee ë
3) DeeHeCe ®eke´Àce®es meYeemeo Deenele keÀe ? nes³e / veener (meYeemeo ke´À. )
4) otjOJeveer ë efveJeeme ë keÀe³ee&ue³e ë ceesyeeF&ue ë F&-cesue ë
5) pevce efoveebkeÀ ë Je³e ë jkeÌleieì ë J³eJemee³e ë
6) íbo ë
7) mebkeÀìkeÀeueerve mebHeke&À ë veebJe ë veeles ë otjOJeveer ë
8) me¿ebekeÀve 2013 ceeefnleer keÀMeer efceUeueer ? 1) Jele&ceeve He$e 2) mebkesÀlemLeU 3) J³eefkeÌleiele mebHeke&À 4) HeefjHe$ekeÀ 5) Flej
9) ì^sefkebÀie®ee HetJee&vegYeJe ë
10) JewÐekeÀer³e Fefleneme DeeefCe De@uepeea ³ee®eer ceeefnleer ëkeÀUeJes
DeeHeuee / DeeHeueer(HeeuekeÀeb®eer mener)Deþje Je<ee&Keeueerue Depe&oejebmeeþer Depe&oeje®eer mener
ieì ke´À.
HeeJeleer ke´À.
efovebekeÀ
RISK CERTIFICATE
This is to certify that I the undersigned / my son / daughter ____________________________________ am / is participating
in Sahyankan 2013 arranged by Chakram Hikers, Mulund on my own risk knowing fully well that the nature of this programme
is adventurous. I also certify that I will not hold Chakram Hikers, Mulund or it’s leaders responsible, either wholly or partially,
for loss of any kind if caused to me/my ward including physical or monetary loss during this programme due to any accident
/ mishap and I will not claim any compensation from them for the same.
(Signature of Guardian) Signature of Participant
For participant below 18 years of age
Sahyankan 2013Organised by
Chakram Hikers, Mulund
Application Form
To,
The President,
Chakram Hikers, Mulund
Sir,
I have read the brochure and rules applicable to Sahyankan 2013 and accept to abide by them. I am depositing herewith a
sum of Rs._____________ /- by Demand Draft / Cheque No. _________________ / Cash towards Sahyankan Fees. I request
you to enroll my name for batch no. _________ or if not available, in batch no._______. My personal details are as under:
1. Full Name :
2. Full Address :
3. Whether member of Chakram Hikers? YES/ NO (Membership No.: _________ )
4. Contact Details :
Tel.: Resi. ___________ Mob.: _______________ Off.: _______________ E-mail : __________________________
5. Date of Birth : ______________ Age : ______ Blood Group: ___________ Profession: _______________________
6. Hobby : _______________________________________________________________________________________
7. Emergency Contact:
Name _____________________________________ Relation: _________________ Tel. No: __________________
8. How you came to know about Sahyankan 2013 ?
News paper article / Web Site / Personal Contact / Members’ Circular / Any other Source
9. Past Trekking Experience : _________________________________________________________________________
10.Medical History & Allergy, if any : ___________________________________________________________________
Yours truly
(Signature of Guardian) Signature of Participant
for participant Below 18 years of age
RISK CERTIFICATE
This is to certify that I the undersigned / my son / daughter ____________________________________ am / is participating
in Sahyankan 2013 arranged by Chakram Hikers, Mulund on my own risk knowing fully well that the nature of this programme
is adventurous. I also certify that I will not hold Chakram Hikers, Mulund or it’s leaders responsible, either wholly or partially,
for loss of any kind if caused to me/my ward including physical or monetary loss during this programme due to any accident
/ mishap and I will not claim any compensation from them for the same.
(Signature of Guardian) Signature of Participant
For participant below 18 years of age
Batch No.:
Receipt No.:
Date: