GGIM One Day Trek Declaration Form

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Name of the participant *

Contact Number *

Email id *

Which group you belong to *

Does the participant or anyone in his/her family have History of Fever in last 15 days ? *

Yes

Does the participant or anyone in his/her family have History of symptoms like cough, cold, sore throat, breathing problems in last 15 days ? *

Yes

If Yes whether treatment was taken for the same from doctor ?

Yes

Clear selection

Does the participant or anyone in his/her family have History of close contact with any suspected corona positive case or patient with serious infective respiratory disorder ? *

Yes

Please provide History of participant's travel, if traveled in last 15 days *

Whether the participant or anyone in the family was advised hospital/home quarantine ? *

Yes

Are you residing in Hotspot zone declared by Govt. ? *

Yes

Has the participant or anyone in family been advised to remain 'Home Quarantine' or 'Institutional Quarantine' by any of the responsible authorities while entering in Pune District? *

Yes

Fitness Declaration & Indemnity / Waiver

Fitness Declaration

I understand the nature of activity I am / my son/ daughter is going to attend is fitness training session, and I declare that I / my son/ daughter does not have any medical prohibition to participate in this activity.

I understand all the regulations and guidelines imposed by government towards the prevention from infection of Covid-19, such as Mask, Sanitizer, & Social Distancing etc. I declare that I/ all my family members shall adhere to all such regulations.

I shall not hold responsible Guardian Giripremi Institute of Mountaineering, Giripremi Mountaineering Club, team of instructors and all the associate members of the organization, in case if there is any illness/injury development to my son/daughter after the fitness session.

Indemnity / Waiver

I declare that, I am registering myself / my son/ daughter voluntarily in the fitness training session planned by Guardian Giripremi Institute of Mountaineering.

I understand that the program will be conducted by with ample safety precautions and I will not hold the Organization or the Organizers / office bearers / staff responsible for any accident / mishap, unforeseen incidence.

The details in the form that I have submitted are true to the best of my knowledge.

I agree to the declaration & Indemnification mentioned above *

Form submitted by (Name of the participant/ parent (in case of minor)) / Name of the Instructor *

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