Registration Form

PARTICIPANT'S NAME: (please print)
AGE:
Date of Birth : Year Month Date

Location :  BROWNES BEACH

DAY :  WEDNESDAY & SATURDAY

TIME :   10.00 A.M – 11.00 AM

CONTACT # IN CASE OF EMERGENCY OR IF CLASSES ARE TO BE CANCELLED:

HOME : WORK : CELL :

ARE THERE ANY SPECIAL MEDICAL CONCERNS WE SHOULD BE AWARE OF? ( Yes or No. If YES PLEASE EXPLAIN)  

DISCLAIMER:
I am fully aware of the risk(s) and hereby give my consent for the above mentioned applicant to participate in the programme offered by the National Conservation Commission (N.C.C)and hereby release any of its elected or appointed officials or instructors from any and all liability from injuries, claims demand cost, loss or service expenses and or damages that may be sustained by me or us or any minor child(ren) on account of his or her participation in said programme or assorted activities or events. I give my permission to the National Conservation Commission to arrange transport of me, my child(ren) or ward(s) by ambulance to a Medical Facility should the situation warrant.

SIGNATURE OF APPLICANT/PARENT/GUARDIAN:
SIGNED BY:
DATE :