Himalayan Back Country Adventures
Near Rose Garden Italian Restaurant, Vashisht temple Road, village Vashisht Teh.Manali, Distt. kullu (H.P.)175103. Cell: +919459392466,919816369466.E-Mail: firstname.lastname@example.org, email@example.com, Web : www.himalayanbackcountryadventures.com, info@himalayanbackcountryadventures (Approved by H.P. Govt. Deptt. of Tourism)
1. Applicant Name: __________________________________Fathers Name ___________________________________________
2. Date of birth: ___________________Age __________Sex____________ Nationality __________________________________
3. Occupation: ___________________ Permanent Address: ________________________________________________________
Pin Code: ______________Telephone Nos. Resi._________________________Cell___________________________________
4. Embassy NOs_______________________________ E Mail ______________________________________________________
5. Passport NOs _________________________________ Place of Issue_______________________________________________
Date of Issue __________________________________ Valid up to _______________________________________________
6. Visa No ______________________________________ Date of Expiry _____________________________________________
7. Blood Group ________________________ Detail of Tour________________________________________________________
8. History of illness/past, present if any ________________________________________________________________________
9. Dated ___________________ Place of Joining _________________________________________________________________
10. Next of kin in case of any accident with address & contact Name: ________________________________________________
Address ______________________________________________________________________Pin Code: ___________________
I agreed to follow strictly to the discipline of the trekking, snow-sports, water-sports, mountaineering and mountain biking adventure etc. Programme and abide by rules of the organization or their authorities at all times during the programme.
I hereby certify that all the entries are correct. I agree to detail myself ___________________________For__________________ ______________________Programme conducted by Himalayan Back Country Adventures, vashisht, Manali (H.P.) at my own risk and no compensation will be paid to me, or my dependants in case of any accident, illness, injury, mishappening or death and I will not hold the organization, its staff or its agents wholly or partially, responsible for the same.
Date____________________ Signature of applicant: ____________________
DECLARATION FORM PARENTS/GUARDIAN (IN CASE OF MINORS)
Certified that my son/daughter/ward/Miss_______________________ is joining ________________ the programme with my consent and the organizers shall Not be held responsible wholly or partly in case of death, any illness, injury or accident. it is also certified that he/ she is physically fit. I, no behalf of my son/daughter/ward agree to abide by the rules regulations laid down by the organizers.
Date: ___________________ Signature of Parent/ Guardian