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2) mebHetCe& HeÊee ë

3) DeeHeCe ®eke´Àce®es meYeemeo Deenele keÀe ? nes³e / veener (meYeemeo ke´À. )

4) otjOJeveer ë efveJeeme ë keÀe³ee&ue³e ë ceesyeeF&ue ë F&-cesue ë

5) pevce efoveebkeÀ ë Je³e ë jkeÌleieì ë J³eJemee³e ë

6) íbo ë

7) mebkeÀìkeÀeueerve mebHeke&À ë veebJe ë veeles ë otjOJeveer ë

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ieì ke´À.

HeeJeleer ke´À.

efovebekeÀ

RISK CERTIFICATE

This is to certify that I the undersigned / my son / daughter ____________________________________ am / is participating

in Sahyankan 2013 arranged by Chakram Hikers, Mulund on my own risk knowing fully well that the nature of this programme

is adventurous. I also certify that I will not hold Chakram Hikers, Mulund or it’s leaders responsible, either wholly or partially,

for loss of any kind if caused to me/my ward including physical or monetary loss during this programme due to any accident

/ mishap and I will not claim any compensation from them for the same.

(Signature of Guardian) Signature of Participant

For participant below 18 years of age

Sahyankan 2013Organised by

Chakram Hikers, Mulund

Application Form

To,

The President,

Chakram Hikers, Mulund

Sir,

I have read the brochure and rules applicable to Sahyankan 2013 and accept to abide by them. I am depositing herewith a

sum of Rs._____________ /- by Demand Draft / Cheque No. _________________ / Cash towards Sahyankan Fees. I request

you to enroll my name for batch no. _________ or if not available, in batch no._______. My personal details are as under:

1. Full Name :

2. Full Address :

3. Whether member of Chakram Hikers? YES/ NO (Membership No.: _________ )

4. Contact Details :

Tel.: Resi. ___________ Mob.: _______________ Off.: _______________ E-mail : __________________________

5. Date of Birth : ______________ Age : ______ Blood Group: ___________ Profession: _______________________

6. Hobby : _______________________________________________________________________________________

7. Emergency Contact:

Name _____________________________________ Relation: _________________ Tel. No: __________________

8. How you came to know about Sahyankan 2013 ?

News paper article / Web Site / Personal Contact / Members’ Circular / Any other Source

9. Past Trekking Experience : _________________________________________________________________________

10.Medical History & Allergy, if any : ___________________________________________________________________

Yours truly

(Signature of Guardian) Signature of Participant

for participant Below 18 years of age

RISK CERTIFICATE

This is to certify that I the undersigned / my son / daughter ____________________________________ am / is participating

in Sahyankan 2013 arranged by Chakram Hikers, Mulund on my own risk knowing fully well that the nature of this programme

is adventurous. I also certify that I will not hold Chakram Hikers, Mulund or it’s leaders responsible, either wholly or partially,

for loss of any kind if caused to me/my ward including physical or monetary loss during this programme due to any accident

/ mishap and I will not claim any compensation from them for the same.

(Signature of Guardian) Signature of Participant

For participant below 18 years of age

Batch No.:

Receipt No.:

Date: