DIRECTORATE OF MOUNTAINEERING & ALLIED SPORTS, MANALI-175131, HIMACHAL PRADESH APPLICATION FORM 1. Name of the Course & Duration: ________________________________________ 2. Name of the Applicant (in block letters)________________________________________ 3. Father's Name: __________________________________________________________ 4. Date of Birth: ____________________5. Age & Sex:__________________________ 5. Educational Qualification :__________________________________________________ 6. Profession: ________________8. Nationality/ Domicile__________________ 7. Nationality/Domicile: ____________________________________________________ 8. Weight & Height:_________________________________________________________ 9. Permanent Address: ____________________________________________________ 10. Present Address: ____________________________________________________ 11. Vegetarian/ Non-vegetarian: ______________________________________________ Experience in Mountaineering/Skiing/Trekking/ ________________________________ Rock Climbing/Water Sports________________________________________________ 12. Size of shoes: (Bata size): ______________________________________________ Certified that the above information is correct to the best of my knowledge, I will abide by the rules and regulations of the Institute and if I indulge in any indiscipline, I will be liable for refund of the whole amount to the Government. ______________________ (Signature of Applicant) RISK CERTIFICATE This is to certify that I agree to detail my Son/Daughter/Ward/Myself _________________ __________________________________________ for_____________________________________ Mountaineering / Skiing / Water Sports,/ Adventure Course in the Directorate of Mountaineering & Allied Sports. Manali (H.P.) at my own risk and no compensation will be paid to me in case of accident and I will not hold the institute or it's staff wholly or partially, responsible for the same. Place:---------------Date:---------------- _____________________ (Signature of Applicant/Parents/Guardian) Note :- Risk certificate for applicant below 18 years of age is to be signed by the Parents/Guardian & for others by applicant himself / herself . Medical Certificate 1. Name: ________________________________________________________________ 2. Age: _____________________________ 3. Weight: __________________________ 4. Respiration rate of rest:________________________ 5. Blood Pressure:____________________ 1. Condition of upper limbs, toes and feet._______________________________________________ 2. Urine examination: ______________________ 8. E.N.T.:____________________________ 3. Blood Test/Blood Group: __________________________________________________________ Applicant should not have Asthma, Epilepsy or other fits and any major deformity, hernia and chronic disease. In my opinion Mr./ Miss. ........... whose signature is given below is fit to under go Basic /Inter mediate / Advance/ Adventure course in Mountaineering/ Skiing / Water Sports. Signature of applicant. __________________ Signature with seal of Medical Officer Date: __________________ Place:__________________ Note: The Medical Officer should be Registered medical practitioner.
