Sidak Application

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SIDAK Registration Form

Instructions: Please read carefully, fill in the information, and sign. If the applicant is under 18 years of age, both theapplicant and their parent/guardian must sign. The application will not be processed if required signatures are missing.

PERSONAL INFORMATION

NAME First Middle Last

ADDRESS No. & Street City State Zip

PHONE Home Cell Work

Email

D.O.B. MM/DD/YR

EDUCATION School/College Grade/Year Major/Minor

FATHER Name Job Title Employer

Email Phone

MOTHER Name Job Title Employer

Email Phone

ADDRESS (if different from applicants) No. & StreetCity State Zip

PROGRAM REQUESTED

Program Applied For: Sikh 101 Sikh 102 Gurmukh 101

Have you attended Sidak before? No YesIf yes, in which program did you participate? Sikh 101 Sikh 102 Gurmukh 101

PAJB/GURMUKH KNOWLEDGE

Gurmukh Script skills (check one):None Extremely Limited Read & Write Fluent

Pajb Language skills (check one): None Extremely Limited Understand & Speak Fluent

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ADDITIONAL INFORMATION

Acceptance into the program will be determined largely by the responses to the below questions. Therefore, please answerthoroughly and use as much space as necessary.

1. How did you hear about Sidak?

2. Please tell us about your past and present involvement with the Sikh community and Sikhi-relatedactivities.

3. Why do you want to attend Sidak?

4. In what areas of Sikhi do you feel you most need to grow and learn? What are yourexpectations of the program?

5. How would you like to apply what you learned at Sidak when you return to your home and/orcollege communities?

Any other considerations you would like to bring to the organizers attention.

MEDICAL INFORMATION

The information in this section is not part of the participant acceptance process. It is gathered to assist in identifyingappropriate care for each participant. All medical information is confidential. If the applicant is a minor, this form must becompleted by a parent or guardian. Any changes to this information that occurs between submission of this form andcommencement of the correlating event should be provided to the Institute prior to the applicants involvement in theprogram. Please make sure to provide detailed and accurate information so the Institute is aware of your (childs) needs.

List any dietary restrictions below.

EMERGENCY CONTACTS

1. Name Relationship Phone

2. Name Relationship Phone

Do you have any physical limitation that might restrict participation in program activities? No YesIf yes, please explain.

Have you required medical treatment for an injury within the last year? No YesIf yes, please explain.

Have you received any treatment for any medical or psychological condition within the last year? No YesIf yes, please explain.

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Is there any medication you currently take regularly?

ALLERGIES

Allergies to MedicationList all knownDescribe allergic reaction and its medical solution

Allergies to Food

List all knownDescribe allergic reaction and its medical solution

Other AllergiesList all known

Describe allergic reaction and its medical solution

MEDICATION

Please list all medications (including over-the-counter and nonprescription drugs) taken routinely. Make sure to bringenough medication to last for the duration of the program. Keep medication in its original packaging that identifies theprescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency ofadministration.

Do you take medication on a routine basis? No YesWill you be taking any prescribed medication during the program? No Yes

If yes, please provide the following information (attach additional pages for more medications)

Medicine Dosage Specific times taken each dayReason for taking

Do you have any of the following medical conditions? (Check all that apply)Asthma Allergies Convulsive Disorders HIV PositiveHeart Problem Pulmonary Disorders Muscular-Skeletal Disorder Diabetes MellitusHepatitis Oitus Media Skin Infection Neurological Disorder Epilepsy Other issues the Institute should be aware of? (Please elaborate)

INSURANCE INFORMATION

Is the applicant covered by family medical/hospital insurance? No Yes

If yes, the insurance carrier/plan nameGroup NumberInsurance AddressName of policyholder (if other than applicant)Relationship to applicantSSN of policyholder or insurance ID

EMERGENCY RELEASE AGREEMENT

Permission to provide necessary treatment or emergency care. In the case of an accident or illness that requiresemergency medical care, I hereby give permission to the attending (licensed) medical personnel to order such medical

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recordings as they may determine, without review by me or my child and without financial or other obligation of anynature to me or my child.

I consent that my child may be identified by name, age, and place of residence or otherwise, as the Institute and/or thoseapproved by the Institute may determine.I release the Institute, its Board of Directors, employees, agents, and volunteers from all claims that I or my child mayhave, or might have, for any cause of action arising out of taking and/or use of the photographs and/or sound/imagerecordings as set forth herein.

This consent and release shall continue in effect, without a limitation of time.

I DO consent or agree to the photo release terms mentioned above.I DO NOT consent or agree to the photo release terms mentioned above.

SIGNATURES

I have read and understood all the registration documents required for my/my childs participation in the Sikh ResearchInstitutes program.Applicant Name (Print)

Applicant Signature ____________________________________ Date

Parent/Guardian Name (Print)

Parent/Guardian Signature ____________________________________ Date

Enclosed with the completed application is:Full Payment in the Amount of $500

Registration Fee of $250 (whereupon the remainder $250 will be due upon arrival)Waiver consideration: If you wish to apply for waiver consideration, please answer the following questions:

1. Amount of Registration Fee applicant is able to pay: $2. Estimated cost of travel (please include flight expenses, cost of visa, etc.): $3. Are you a: High School Student College Student Employed4. Martial Status: Single Married Divorced/Separated Number of Dependents5. Please explain any unusual expenses, other debts, or special circumstances that the Institute should consider

when deciding how much to sponsor your participation. Use additional paper if necessary.

Applications for waiver consideration will be accepted up until the application deadline. Completed applications will beconsidered on a first come, first serve basis while funding is available. Applicants will be notified 15 days after the

receipt of their application.

REFUND POLICYAll refund requests must be received within 10 days after the first day of the program not attended; up to 50% of theregistration fee will be refunded. In the event that a participant must be dismissed from the program for any reason, norefund will be made except for certifiable illness.

Please send the signed registration form with fee (make checks payable to the Sikh Research Institute) to:Sikh Research Institute | P.O. Box 690504 | San Antonio, TX 78269-0504.

If you have any questions, please contact us at: 210.582.3371 [email protected].

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mailto:[email protected]:[email protected]:[email protected]:[email protected]


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OFFICE USE ONLY

Application Approved Denied Reason for Denial

Reviewed By Date

Acceptance Notified No Yes Date

Sponsorship Approved Full Partial Other

Sidak Application

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