DPS - Modern Indian School

Doha, Qatar
APPLICATION for Participating in Swimming Class
Name
:
Birth Date

Nationality

Class

Telephone

Address

Email

:
Pledge

I ___________________________father / Guardian of ____________________ Studying in

___________hereby pledge to allow my ward for Swimming Class on my own responsibility and
he / she doesn't suffer from any of the following that bar him / her from participating in the
class.

Neurogenic as spasmademic
Circulatory
Respiratory
Skin Diseases

:
:
:
:

Signature of Parent
----------------------------------------------------------------------------------------------------------------------------Medical Check-up has been conducted on _____________and he proved to be:
1- Medically Fit.
2- Medically unfit.
For participating in Swimming Class.
Date:
Doctor:
Signature of Doctor