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ECO TREKS GOA enrolment form .pdf


Original filename: ECO TREKS GOA enrolment form.pdf
Title: ECO TREKS GOA
Author: DVParab

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ECO TREKS GOA
Enrollment Form
Office No. 9, Business Point, Above Bicholim Urban Bank, Angod, Mapusa, Goa. Ph. 2251444 Mob. 9422445444

Camp Name:

Camp date:

(Form to be filled in Capitals)
__________________________

Form

Details as per ID. no.:

Camper’s Name __________________________________________________________________
(Last Name / Surname)
(First Name)
(Middle Name)
Address_________________________________________________________________________
________________________________________________________________________________
__________________________________________________ Pin: _________________________

Tel. No.: Std Code: (_____

_) Home: __________________________________________________

Camper’s Mobile:_______________________ E-mail: ___________________________________
School / College / Firm:____________________________________________________________
Date of Birth : ____/____/_______
dd

mm

Age : ________

Male /Female _____

yyyy

Contact Name and Number in Emergency: ____________________________________________
Parents’ Profession: ______________________________________________________________
Blood Group

____________________________

Medical problems and allergies: _____________________________________________________
________________________________________________________________________________
DECLARATION
I have read all the rules and regulations and I agree to abide by them and the instructions given by the camp
organizers at all times during the camp. In case of any injury, sickness, accident, death or any other casualty or loss
of valuable/luggage, myself, my parents, my guardians, relatives and friends shall not hold the organization, the
instructors, any other staff, wholly or partially, either individually or jointly responsible. I am aware that only first
aid is available on camp site and in case of any injury or sickness, I am ready to take medical treatment from doctor /
attendant, if available on camp site and /or from the nearest available medical centre / hospital. The expenses for the
same will be borne by me.
Place:
Date:

Signature of Parent / Guardian

Signature of the Camper

ECO TREKS GOA
MemberEnrollment Form
Office No. 9, Business Point, Above Bicholim Urban Bank, Angod, Mapusa, Goa. Ph. 2251444 Mob. 9422445444

Trek Name:

Trek date:

Form

(Form to be filled in Capitals)

__________________________

Treker’s Name __________________________________________________________________
(Last Name / Surname)
(First Name)
(Middle Name)
Address_________________________________________________________________________
________________________________________________________________________________
__________________________________________________ Pin: _________________________

Tel. No.: Std Code: (_____

_) Home: __________________________________________________

CTreker’s Mobile:_______________________

E. Mail : ______________________________

Re Confirm E-mail: ( In Block Letters ) ___________________________________

Profession :

____________________________________________________________________

School / College / Firm:____________________________________________________________
Date of Birth : ____/____/_______
dd

mm

Age : ________

yyyy

Contact Name and Number in Emergency: ____________________________________________
Blood Group

____________________________

Medical problems and allergies: _____________________________________________________
________________________________________________________________________________
DECLARATION
I have read all the rules and regulations and I agree to abide by them and the instructions given by the trek
organizers at all times during the trek. In case of any injury, sickness, accident, death or any other casualty or loss of
valuable/luggage, myself, my parents, my guardians, relatives and friends shall not hold the organization, the
instructors, any other staff, wholly or partially, either individually or jointly responsible. I am aware that only first
aid is available on trek site and in case of any injury or sickness, I am ready to take medical treatment from doctor /
attendant, if available on trek site and /or from the nearest available medical centre / hospital. The expenses for the
same will be borne by me.
Place:
Date:

Signature of Parent / Guardian ( in Minor )

Signature of the Treker


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