Department of Adventure Sports and Youth Affairs

Swarnim Gujarat Sports University,

Gandhinagar
Application Form
Course Applied For: ___________________________________
Date: _______________________________________________
Preference : (if applicable & offered) Morning / Evening ______
Fee Details: DD No. ________, Date: ___________

Passport Size
Photograph
(Please do not Staple)

Name

: _________________________________________________________________

Date of Birth

: _________________________________________________________________

Address

: _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Contact No. - ______________________________________________________

Next of Kin

: Name -_______________________________ Relation - ____________________

Contact No. - ______________________________________________________

Organization/Institute

: _________________________________________________________________

Designation

: _________________________________________________________________

Academic Qualification

: _________________________________________________________________

Adventure Sports & Allied

: _________________________________________________________________

Qualification/Experience if any _________________________________________________________________

I have carefully read the entire form, said rules and conditions and I accept and abide by the same
and the information provided by me is true and correct to the best of my knowledge.

Full Name and Signature of Parents/Guardian

(in case of participant is minor)

Full Name and Signature of Participant

ACKNOWLEDGMENT AND ASSUMPTION OF RISK, RELEASE AND INDEMNIFICATION:

In consideration of the training and services provided by Swarnim Gujarat Sports University,
its officers, employees, volunteers, participants and all other persons or entities associated with or
acting in any capacity of its behalf, I hereby agree to release, indemnify and discharge Swarnim
Gujarat Sports University, on behalf of myself, my heirs, assigns, personal representative and
estate and for all members of my family, including minor children, as follows:
I acknowledge that adventure activities and extreme sports entail known and unanticipated
risks that could result in physical or emotional hazards, injury, death or damage to me,
property and/or third-parties.
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 I expressly agree and promise to accept and assume all of the risks existing in this activity.
My participation in the activity is purely voluntary and I elect to participate in spite of the
risks. I hereby voluntarily release, forever discharge and agree to indemnify and hold
harmless Swarnim Gujarat Sports University from any and all claims, demands or causes of
action which are in any way connected with my participation in this activity or my use of
equipment or facilities provided by Swarnim Gujarat Sports University including any such
claims which allege negligent acts or omissions of Swarnim Gujarat Sports University.
I certify that I have adequate insurance to cover any injury or damage I may cause or suffer
while participating, or else I agree to bear the coasts of such injury or damage myself. I
further certify that I am willing to assume the risk of any medical or physical condition I may
have.
I have had sufficient opportunity to read this entire document. I have read and understand it,
and I agree to be bound by its terms.
I give my assurance to follow all rules, regulations and instructions given by instructor/coach
during the course.
Date:

Place:

Full Name and Signature of Participant

ADDITIONAL INDEMNIFICATION BY PARENTS OR GUARDIAN:

(Must be completed for participants under the age of 18 years)

In consideration of ________________________________________ (name of
applicant/minor) being permitted by Swarnim Gujarat Sports University to participate in its
course/training/trip/activities, as the parent or guardian of mentioned applicant, I hereby give my
permission to participate in the foregoing and further agree, individually and on behalf of minor,
to the term of the above and to indemnify and hold harmless Swarnim Gujarat Sports University
from any and all claims which are brought by or on behalf of Minor, and which are in any way
connected with such use or participation by Applicant/Minor.
Date:

Place:

Full Name and Signature of Parents/Guardian

MEDICAL CERTIFICATE: (to be signed by RMO/Physician or Registered Medical Authority)

Age:

Years Height:

cm, Weight:

kg.

Blood Group:

Space to write any significant finding or advise:

Certificate:
This is to certify that Mr. /Ms. _________________________________________ is
physically and mentally found fit on his/her examination, to undergo sports climbing,
mountaineering and any adventurous training activities.

Seal & Signature of Doctor

Date

Full Name, Address & Registration No.

(Photocopy of this form can be used)

Government Commerce College Campus, Opp. Youth Hostel, Near G-4 Sector 15, Gandhinagar 382016
Phone No. (079) 23288364, E-mail: info.sgsu@gmail.com

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SWARNIM GUJARAT SPORTS UNIVERSITY, GANDHINAGAR

This summer

SGSU

organize

BASIC
SPORTS
CLIMBING
COURSE
WHEN

May 1st to 5th, 2015

WHERE
Eklavya Sports Academy
NEAR HOTEL CAMBAY GRAND, THALTEJ, AHMEDABAD.

LAST DATE OF REGISTRATION

28th April, 2015

This summer reach a

litter higher @ SGSU
courses

AGE GROUP
Above 8 Years

COURSE FEE

500/- per Participant

(Course fee includes only training and assess to
learning and study materials during the course. No
lodging, boarding and transportation facilitates will
be provided from the organizer)

(The participant shall pay non-refundable

course fee only through a Demand Draft
drawn on any nationalized bank, in favour
of Registrar, Swarnim Gujarat Sports
University)

CONTACT PERSON
Y L Jethwa
9924124911
jethwayl@gmail.com

CONTANT US @

Department of Adventure Sports & Youth Affairs,

Swarnim Gujarat Sports University,
Govt. Commerce College Campus,
Opp. Youth Hostel,
Sector 15,
Gandhinagar 382 016
http://www.sycd.gujarat.gov.in/

Registration form can be avail from

SGSU, University Office (Contact Person Y L Jethwa, Mobile No.9924124911)
Request can be made for registration form to jethwayl@gmail.com
Eklavya Sports Academy from 06:00 pm. To 07:00 pm. (Contact Person Dhruv Oza, Mobile No.9429575978)

*Limited seats are available on first come first sever basis, please get yourself registered.
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