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AINDIAN INSTITUTE OF TECHNOLOGY DELHI

BOARD FOR SPORTS ACTIVITIES

Swimming Pool Membership Form(For Students)

Name: Tanmay Sahni Entry No.: 2011CE10407

Fathers Name: Kishor Kumar Sahni

Department: Civil Engineering

Age: 21 Sex : Male

Knows swimming (Write Yes or No): Yes

Hostel : Kumaon Room No. : NC-24

Mobile No. : 9650474819

Preferable days: Tue/Thu/Sat OR Wed/Fri/Sun (Tick any one) Preferable slot:

Emergency Telephone No : 0751-2422476

Residential Address : C-36,37 Vijayanagar, Lashkar, Gwalior, Madhya Pradesh - 110016

Medical Examination Report

(Note: Please bring your IIT Medical booklet for Medical Examination)

(A)To be completed by the applicant

Identification Mark: Black spot on right cheek

Blood Group: B+

History of any of the following (If yes, Give details)

Epilepsy : No

Bronchichial Asthma : No

Heart Disease: No

Diabetes: No

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Hypertension: No

Psychiatric Problem: No

Whether suffering from Eye infection: No

Ear Discharge: No

Skin Disease: No

Whether using (i) Spectacles: No (ii) Contact Lenses: No

Specify any known Allergy

(Sig. Of Student)

(B)To be completed by Medical Officer

I have examined Prof./Dr./Mr./Ms..___________________________________ S/O,/

D/O,/ W/O________________________________ and certify that he/she is fit to join swimming

pool.

Signature of Medical OfficerDate Name with seal

Pay Rs. ___________ as the swimming pool membership fee in the SBI, IIT Delhi

branch in the Vice-President, BSA A/c No. 10773569325. Please deposit duly filled

application form, photocopy of identity card, bank counterfoil and two stamp size recentphotograph in the sports office for the issue of the membership card.

Valid Up to ____________

Membership No. ____________

Day & Slot ______________________

(Sports Office) (Sports Officer)

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