Sr.No.

_____(Off Use)
OUTWARD BOUND BHARAT

FORM OF PARTICIPATION & DECLARATION

1. Name of the participant : ______________________________________________

2. Sponsored by : ______________________________________________
3. Postal Address : ______________________________________________
______________________________________________
______________________________________________
Pin Code: ____________________
4. Phone No. : _______________________________________________
Mobile No. : _______________________________________________
Emergency Contact No : _______________________________________________
5. Date of birth : / / Age : ______ years (Completed)
6. Sex : Male / Female (Please Tick)
7. Email Address :_______________________________________________

DECLARATION
I wish to participate in the activities conducted by Outward Bound Bharat.
I hereby declare that:
A) The above entries made by me are correct.
B) I am aware of the nature of possible risks associated with outdoor activities.
C) I shall abide by the code of conduct of the program.
D) I shall adhere to all safety norms prescribed by the organizers.
E) I will be fully responsible for my own safety during my participation in the activities and will
not hold the organizers responsible for any injury or mishap during my participation.
F) I am medically fit to participate in the outdoor activities.

Participant’s Signature Parent’s / Guardian’s Signature

(For Minors)

Date: ___________ Place:___________

(See backside)
Please furnish the medical details requested below for proper care and to prevent any
recurrence & possible emergency due to previous ailment..

MEDICAL

1) Your normal pulse: ____________________.

2) Normal blood pressure: ____________________.

3) Known allergies:
a) Medicine: __________________________________.
b) Food: __________________________________.
c) Insects: __________________________________.
d) Plants / Pollens: __________________________________.

4) Current medication (If any): __________________________________

__________________________________.
5) Medical history (If any):
a) Fracture: __________________________________.
b) Dislocation: __________________________________.
c) Back / Neck pain: __________________________________.
d) Surgery: __________________________________.
e) Heart: __________________________________.

6) Level of fitness: Average / Good / High. (Please tick).

7) Accident Insurance: __________________________________.

Participant’s Signature Parent’s / Guardian’s Signature

(For Minors)