Self Declaration Form
Uploaded by
bhupsjangirSelf Declaration Form
Uploaded by
bhupsjangirREGISTRATION FORM
(Please fill completely, legibly and in detail)
Name: _______________________ _____________________ _______________________
First Middle Last
Residential Address: __________________________________________________________________
___________________________________________________________________________________
Day Phone: ____________________________ Residence Phone: _______________________
Mobile: Email:
Date of Birth: __________/_______________/_________________ Gender: (M/F)
DD MM Year
Height: _________________ft Weight: ______________ Kgs * Blood Group: ________________
Emergency Contact Person:
Name: ________________________ __________________ _______________________
First Middle Last
Your relation with the person mentioned above ________________________________________
Residential Address: _____________________________________________________________
______________________________________________________________________________
* Residential Phone: _____________________ * Mobile _________________________
* IMPORTANT - Please Furnish Details
Physical Condition:
Do you have any medical condition(s) that we should know about (Prior Joint Dislocations, Allergies, Diabe-tes,
Asthma, or any other condition that you would like to share)? __________________________________
______________________________________________________________________________________
______________________________________________________________________________________
List any prescription medication (s) you are presently taking? _____________________________________
Personal Doctor (If any)
Name: _______________________________________________________________________________
Residential Address: ____________________________________________________________________
_____________________________________________________________________________________
Day Phone: ________________ Residence Phone: _________________ Mobile: ___________________
Please Turn Over
Regd. Address: 11/114 New Housing Board Colony Sikar - 332001, INDIA
Email : info@evergreenadcon.com
Jaipur Office: F-178, Time Square, Central Spine, Sector-2, Vidyadhar Nagar,
Jaipur- India Mobile No 9571601491
DETAILS OF THIS PROGRAM …………………………………………………………………………………….
Dates ……………………………………………… Venue ………………………………………………………..
DECLARATION
I understand that, being outdoors has its own charm. However, it also brings its share of hazards. It is
important that even though the best of equipment is involved and all the logistics being taken care of,
participants and their parents/guardians must be aware of the realities of the many possible hazards in
undertaking any adventure activity; these include, but are not limited to:
1 Sudden change in, and extremes of, weather conditions;
2 Equipment Failure;
3 Natural calamities like Land Slides, Floods, Avalanches;
4 Falls on steep or difficult terrain, that is dangerous or difficult to negotiate, including dense bushes,
rough and slippery ground including sand and rock;
5 River crossings;
6 Getting lost in remote or inaccessible areas;
7 Encounters with wildlife;
8 Bites from insects and reptiles;
9 All other risks, hazards and dangers associated with outdoor activities;
10 Discomfort due to travel to and from activities.
The following events and conditions can contribute to the inherent risks of the activities:
1) Inappropriate or inadequate equipment or clothing;
2) Poor or inadequate physical fitness or health;
3) Failure to obey the directions of instructors or leaders or facilitators;
4) Failure to exercise good judgment or due care and attention.
The best way to minimize such risks is to be conscious of them and act proactively. Keep learning at every
opportunity and leave all egos at home. Enjoy the outdoors for yourself, never for anyone else’s opinion. It
is understood that for safety of all members of the team, every participant must be committed to the
highest standards of safety and responsible behavior. Failure to do so could result in immediate removal
from the activity in question. All instructions detailed by the leader/ instructor/ facilitator must be adhered to
at all times.
I declare that I am medically fit and am participating in the program, perfectly aware of the risks involved. I
further declare that Evergreen Adventures & Consultancies & its representative in this behalf shall not
in any way be liable to me or to 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 program.
Date:
Place:
Signature of participant
Regd. Address: 11/114 New Housing Board Colony Sikar - 332001, INDIA
Email : info@evergreenadcon.com
Jaipur Office: F-178, Time Square, Central Spine, Sector-2, Vidyadhar Nagar,
Jaipur- India Mobile No 9571601491