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APPLICATION FOR PARTICIPATION IN

35th ROCK CLIMBING TRAINING COURSE P.og,u,-.

Heldat..''''..''..'I':.v:.*l.1i.I:}.l.l.*::Ji::w..-":1B.1g:1'...............Starting from 18.01.2020, Saturday To 21.01.2020, TuesdaY

l. Name Mr./Mrs./Miss

(Full name in block letters)

2. Father's/ Husband's name ..........

4. Sex .................. 5. Date of birlh 6.Telephone No .."""""" "'(Resi')

8. Occupation 9. KTY Membership No .'.........."

10. Designation & Office address

11. Previous experience of similar activities (attach a seperate sheet if needed) ............"

12. Vegetarian/Non-Vegetarian ....... 13' Hobby

14. Next of kin (Relationship, Name & Address with Tel. No.) ...-.'....'

15. Equipments/articles which shall be issued by the Club will be returned within two days from the date

of arrival at Kolkata or as may be decided by the Course Leaderl Organiser, failing which I shall pay

maintenance charges as per Club's rules.

16. I will write the daily diary during the programme and will surrender it to the course leader after the

programme is over.

I, ................. ....agree to adhere strictly to the discipline of the

programme ancl abicle by the directions-of the organisers at all times during the programme.

In case of any accident, illness or injury, I will not hold the any other parlicipants,course-conducting

committee, instructors or course leader of Kolkata Trekkers Youth or its members responsible in

any way during the arrival & departure for the same and also during the programme period.

I am sending the parlicipation fee of Rs. .,................ by M.o/cash/Bank Draft No .'............

Dated.........

I have the following equipment to be used for this programme : """""""""

Signature

PARENT'S/GUARDIAN'S CONSENT(To be filled in by those under 18 years of age)

!t is certified that my son/daughter/ward Mr./Mrs./Miss.........

isjoining35th ROCKCLIMBINGTRAININGCOURSE programmewith myconsent.ln case

of any accident, illness or injury, I will not hold the other participants, course-conducting

committee, lnstructors or course leader of Kolkata Trekkers Youth or its members

responsible in any way during the arrival & departure for the same and also during the

programme period.

Signature of parent/guardian

(Relationship with the applicant)

FOR OFFICE USE ONLY

1. Date of receive of application ...........,.

2, Received Rs. ..,...... .... Vide Receipt No............. .Dated

Conflrmation sent on .............

3. Certificate's Roll No. KTY/ B/ I 20 I / 35th Dated

4. Grading (............ .........)

5. Graduation Ceremony held at

6. Remarks:

on 2020