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

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 applicant’s)

No. & Street

City State Zip

PROGRAM REQUESTED

Program Applied For: Sikhī 101 Sikhī 102 Gurmukhī 101Have you attended Sidak before? No YesIf yes, in which program did you participate? Sikhī 101 Sikhī 102 Gurmukhī 101

PAÑJĀBĪ/GURMUKHĪ KNOWLEDGE

Gurmukhī Script skills (check one):None Extremely Limited Read & Write FluentPañjābī Language skills (check one):

None Extremely Limited Understand & Speak Fluent

Sidak

ADDITIONAL INFORMATION

Acceptance into the program will be determined largely by the responses to the below questions. Therefore, please answer thoroughly 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 organizer’s 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 applicant’s involvement in the program. Please make sure to provide detailed and accurate information so the Institute is aware of your (child’s) needs.List any dietary restrictions below.EMERGENCY CONTACTS1.

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.

Sidak

Is there any medication you currently take regularly?ALLERGIES

Allergies to Medication

List all knownDescribe allergic reaction and its medical solution

Allergies to Food

List all knownDescribe allergic reaction and its medical solution

Other Allergies

List all knownDescribe allergic reaction and its medical solutionMEDICATIONPlease 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 the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.Do you take medication on a routine basis? No YesWill you be taking any prescribed medication during the program? No YesIf yes, please provide the following information (attach additional pages for more medications)Medicine Dosage Specific times taken each dayReason for takingDo 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 INFORMATIONIs the applicant covered by family medical/hospital insurance? No YesIf yes, the insurance carrier/plan nameGroup Number Insurance Address Name of policyholder (if other than applicant)Relationship to applicantSSN of policyholder or insurance IDEMERGENCY RELEASE AGREEMENTPermission 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