@
MODERN SCHOOL www.modernschool.net
Barakhamba Road, New Delhi, India Phone : 91 11 23311618-20 : Fax 91 11 23316214 email :
[email protected] &
[email protected]
REGISTRATION FORM FOR STUDENTS
Please Affix recent photo here
Name of the Participant: _______________________________________
School : _____________________________
Country : ______________
PARTICIPANT’S PERSONAL INFORMATION Full Name in Block (as in Passport)
Sex
Blood Group
Height (in Cm.)
Weight (in Kg)
T-Shirt Size (S/M/L/XL)
Date of Birth (DD/MM/YYYY)
Age on 01/10/2009
Home Address
Email
Home Phone (
Mobile Phone
)
Country of Birth
(
)
Nationality
Passport Number
Passport Expiry Date
Passport issuing Country
Special Dietary Requirement (e.g. Vegetarian / Non-Vegetarian)
PARENT’S/ GUARDIAN’S PERSONAL INFORMATION: Full Name in Block (as in Passport)
Email Id
Office Telephone Number
Mobile Telephone Number
(
)
(
)
(
)
(
)
EMERGENCY CONTACT’S PERSONAL INFORMATION: The following person may be contacted in cases of any emergency: Full Name in Block (as in Passport)
Home Number (
)
Office Number (
)
Mobile Number (
)
SCHOOL DETAILS: Name of School
Name of the Principal/Head of the School with Email-id
School Address with Phone & Fax Number
School Website & Email Address
Participant’s
Class/Year/ Level
as of 01/10/2009
Grade 9 / 10 / 11 / 12
LEADERSHIP PROFILE: Please briefly describe all leadership activity & positions held in the past year/ current year/ would be holding in the following year:
PERSONAL HEALTH PROFILE:
My general state of health is:
Good
Fair
Poor
My level of fitness is:
High
Medium
Low
Are you currently taking medication?
Yes / No
If yes, please specify:
Have you been hospitalised in the past 12 months? Yes / No If yes, please provide details:
PARTICIPANT ACKNOWLEDGEMENT FORM (TO BE COMPLETED AND SIGNED BY PARTICIPANT)
I, _______________________________________________ [participant name in full], hereby declare that the information given is true and comprehensive.
I fully understand that the activities carried out by The CDLS Organising Committee may be mildly to moderately physically demanding. I will not hold The CDLS Organising Committee responsible for any loss of personal property or any injuries sustained during the course of the programme.
I will ensure that I understand and adhere to all activity instructions and accept any associated risks involved.
___________________ Signature of Participant
_________ Date
PARENTAL CONSENT FORM (TO BE COMPLETED AND SIGNED BY PARENT/ GUARDIAN OF PARTICIPANT)
I, _______________________________________________________ [name in full], parent/ guardian of child/ward,
___________________________________________________ [child’s/ward’s name in full]
hereby give permission for him/her to attend Community Development And Leadership Summit, from Saturday 7th November to Sunday 15th November 2009, to be hosted by Modern School, Barakhamba Road, India. I also understand that some of the activities in this convention may be physical in nature and will be held outdoors. I also understand that my child’s / ward’s comfort and safety may be dependent on his/her bringing the stipulated equipment and his/her exercising good judgment whilst participating in all activities. I hereby declare that all the medical information provided above is accurate. I authorise The CDLS Organising Committee to obtain medical assistance when they deem necessary in the event of any illness or accident suffered by my child / ward. I agree to pay for any medical and emergency transport services incurred on his/her behalf. I hereby declare that I will not hold The CDLS Organising Committee responsible for any damage to or loss of personal property or any injuries sustained by my child/ward during the course of the programme. I certify that the information provided on this form is true and comprehensive.
________________________ Signature of Parent/ Guardian
_______ Date
VERIFICATION
BY SCHOOL
It is to certify that the information provided above by the student is true as per our school record.
______________________ Signature of School Liaison
________________________ Name of the School with Seal
_______ Date
For further enquiries, contact us via email at
[email protected]. OR
[email protected]
