s kwYu

VYAKTI VIKAS KENDRA INDIA

k rfkMk fuL

Vkuxku

SHAKTI KRIYA WITH POOJYA GURUJI

REGISTRATION FORM

(30, 31 OCTOBER 2013 - AGE LIMIT - 55 YEARS)

TIME : MORNING 8.30 TO 10.30 AM

Name
Surname
Middle Name
Name :Lkk{ ...............................................................................
Sex: Male kwYk

Female e

Age {h.........

(IN CAPITAL)

Full Address kqYt MkhLkk{wt...........................................................................................................................................

..................................................................................................................................................................................
City nuh......................State hk........................... Pin keLk........................ Email E.{uE......................................
Phone(R) VkuLk(hnu.)...............................Phone(O)VkuLk(yku.)............................ Mo.No {ku.Lkt........................................
Occupation Mkk.............. Address MkhLkk{wt ...................................................... Date of Birth sL{kkhe......................
Courses done
fhu fkukoLke rkkku
Basic kuef
Advance-I yuzkLMk-I
Advance-II yuzkLMk-II

Date kkhe

Place Mk

Teachers Name rkfLkwt Lkk{

Recommending Teachers Name..................................................... Code........................... Sign..........................

Vku{o hkLkkh rkfLkwt Lkk{ ............................................fkuz Lkt............................Mkne :......................................................
DD in favour of VVKI Gujarat Apex Body Payable at Ahmedabad A/C. No. Punjab National Bank 1003000101069544
Donation Details : Cash: D.D. No........................................................ Dated....................................................
Bank ............................................................... Branch : .............................................. City : ...................................
Through NEFT - IFSC code.......................

Catagory (fkh)
A/C Room (2 rfk)

Accomodation / hnukLke Mkk

Code (fkuz)
1 Night
2 Nights
rkk
A1
A2

Your Choice (k{khe kMktke)

fkuz

NonA/C Room (2 rfk)

B1

B2

Shakti Kriya

Dormitory (zku{eoxhe)

D1

D2

hnukLke Mkk

hnuXkLke Mkk sYrhkk {wsk fhe ykkewt. kuLkk {kxu knuuke skwt.

kukkLk

---------

fw kukkLk

Acknowledgment

(rfkrk kkMk {kxu yk Mek sYhe Au.)

Name Lkk{.............................................................................................................
Address MkhLkk{w : ....................................................................................................................................................
Donation Details..........................................Rs...................................Cash/D.D. No...........................................
yLkwkLkLke rkk..................................................... Yk..................................... fu / ze.ze.Lkt..................................................
Bank kUfLkwt Lkk{......................................................................Branch kk...............................................................
Full Name of Receiver..............................................Phone.......................................Sign...................................
kiMkk uLkkhLkwt kqt Lkk{.........................................................VkuLk Lkt.........................................Mkne....................................
VVKI Gujarat Apex Body 272, Mayurpankh Society, B/h Shaligram Flat, Satellite, Ahmedabad-380015
Contact No. 079 26733031 / 9825822398 / 079 26763030 / 9879610400 / 9067840405

 In order to determined your participation Shakti Kriya, Please answer the questions below
accurately and completely (krk{kt kk uk {kxu Lke[uLkk kuLkkt [kufMkkEkqof skk ykkku.)
1. k{u ykhu fkuE k E hkk Aku, kku kuLke ke ykkku
Are you on any medication, Please enlist
2.

k{u zkxhLke xex{uLx E hkk Aku ? MkkEfeykxeMx MkkfkukuSMx ykk keS fkuE5 xex{uLx E hkk nku kku skku.
Are you under the care of a physician including Psychiatrist / Psychologist or any other therapist ?

3.

Auk A {rnLkk{kt k{u fkuE Mksohe fhke nku kku skku.

Please mention about any surgeries you have had in the past 6 months ?

4.

k{Lku fkuE qtx ykk fhkuzLke kfeV nku kku skku. yuLke fkuE Mksohe qkfk{kt fhke nku kku k skku.
Do you have any difficulties with your knee or spine ? any surgeries done ?

5.

k{Lku nkE / ku z uh Au ? skku

Do you have High / Low Blood pressure ? Please mention
u nku kku k{u fE k E hkk Aku, kuLkwt eMx ykkku.
If you are on medications for Blood Pressure Please give their names.

6.

7.
8.

rLkr{k k ek kAe k{kt zuh fuxtw hnu Au ?

What is you regular BP with medication ?
kehez{kt yLku uLkuLkLx nku ku eyku k rk Lkrn fhe fu
For Women : Shakti Kriya is strictly not permitted during Menstruation & Pregnancy.
Vku{o Mkkku zkufxhLkwt Veef VexLkuMk MkxeorVfux uzwt sYhe Au.
Doctors certificate for physical fitness must be attached with the form.

Declaration
I have answered the above questions honestly and completely. I have been fully advised and I knowingly
take full responsibility for my experience and outcome. I do not hold AOL, VVM, IAHV (or any associated
personnel of these organizations) responsible for my results. I release Vyakti Vikas Kendra, all organizers
and assistants from all damages whatever and waive all right to compensation in case of injury. I declare
that I am physically and mentally able to participate in this program.
Name.................................................... Date........................................
Sign..............................................
5iMkk koLke kUfLke ykuheSLk Mek ykk ze.ze. Vku{o Mkkku uzk.
Please attached Bank Slip
krk fhkk 5nuk Mk kh kfkhe kkkMk{kt kkMk Lkrn kLkkhLku kqhukqt kh kkAwt ykkk{kt yku.
It is mandatory to pass medical test at the venue. Participant will get full refund in case of rejection.

sYhe Mkq[Lkkyku :
1. krkLkk MkkLk kh fkuEk f{ke Mkwyku Mkkku Lk hke.
2. kkeLke kkux, {kukkE, rzk, [k{zkLke Mkwyku fu yL [eu Mkkku hke Lkn.
3. k{Lku ykkk{kt yku krkLkk kkMk y[qf Mkkku ELku ykk. kuLkk kh u {u Lkrn.
4. LkkLkk kkfku Mkkku ke fku Lkn.
5. Mkkhu nku LkkMkku fhku su{fu q yLku V.
Venue : Exhibition Hall, University Convention Hall, Nr. Helmet Circle, Memnagar, Ahmedabad.