1 st ADVENTURE TREKKING CAMPING COURSE- 2015

Route: Phaparkheti – Lakethang – Lilakha - Doley Camp in Neora Valley National ParkFrom: 25th Feb. – 1st March, 2014

Organised by

Mystic VoyageAPPLICATION FORM

1. NAME (in block letter) :

2. GUARDIAN’S NAME :

3. PRESENT / PERMANENT ADDRESS :

4. MOBILE NO. & Email :

5. DATE OF BIRTH (age) :

6. EDUCATIONAL QUALIFICATION / OCCUPATION :

7. NAME & ADDRESS OF THE INSTITUTION /OFFICE :

8. PREVIOUS EXPERIENCED IN ANY ADVENTURE COURSE? DESCRIBE :

9. WHETHER A MEMBER OF ANY OTHER ORGANISATION / ADVENTURE CLUB :

10. FOOD HABIT (veg / non veg) :

11. OUTDOOR ACTIVITIES (Mountaineering/Trekking/Rock Climbing/Camping etc) :

12. BLOOD GROUP & ANY HISTORY OF ALLERGY : ( ) VE /

I shall abide by the rules and regulations of the organization and Adventure Trekking Camping Course 2015 and will maintain perfect discipline. In case of any injury, accident or any unforeseen eventualities, I will not hold any member or the Foundation wholly or partially responsible in anyway.

Date:Signature of the Applicant

DECLARATION OF GUARDIAN(FOR BELOW 18 YRS. AGE PARTICIPANT)

I am allowing my Son / Daughter Sri/Smt …………………………………………………………………………………………. to attend the Adventure Trekking Camping Course 2015. In case of any injury, accident or any unforeseen eventualities of my Son / Daughter, I will not hold any member or the Foundation wholly or partially responsible in anyway.

Date:

Signature of the Guardian