Serial No.

APPLICATION FORM FOR LOCAL TREKS ONLY

Name of the Trek / Programme
Organised by :

YUVASHAKTI, PUNE
388, Narayan Peth, Rastrabhasha Bhavan, Pune 411 030. Tel. : 65221111, 24456696, 9623667788
e-mail : yuvashaktipune@gmail.com z www.yuvashakti.org.in

Caution : This Application form must be filled fully by the participant only.

1. Name : Shri / Smt.

(IN FULL & BLOCK LETTERS, SURNAME FIRST)

2. Address :
(with nearest landmark)

Pin. :

Phone No. : (R.) (O.) :

e-mail id : --------------------------------------------------- Mobile :

3. Date of Birth Age :

Blood Group : Sex : Male Female

(Compulsory)

INDEMNITY BOND / DECLARTION

I son / daughter / wife of

having agreed to take part in the programme organised

by Yuvashakti, do solemnly declare that I am doing so at my own risk and responsibility. I further declare that any
person authorised by the above mentioned organisation on their behalf shall not, in any way, be liable to me or my
dependents, legal heirs, successors or to any other person for any loss, damage, disability or injury sustained by
me or for death resulting from my participation in the above mentioned programme. The aforesaid organisation and
any person authorised by them shall not be liable to pay any compensation, by whatever name called, to me or to
my dependents, legal heirs, successors or to any other person. I agree to adhere strictly to the discipline of the
programme and abide by the directions of the organising authorities or their nominees, at all times during this
programme.

Date : Signature of Participant

Place :

RISK CERTIFICATE
(In the case of applicant below 18 years.)

It is certified that my son / daughter / ward / Mr. / Miss.

is joining the programme with my consent and the organisers shall not be held responsible for any illness, injury,
accident or death beyond their control. It is also certified that he / she is physically fit to undergo the rigours of this
programme
Amount Received Rs. :

Signature of Parent / Guardian

Note : All Claims Subject to Pune Jurisidction only.
(Relationship with the applicant)