Consent Form
To be completed by every student (or guardian) attending any YOUTH PROGRAM at MSA. If the youth has not completed 18 years as of TODAY, this consent form must be completed by the guardian.
Email address *
Program *
Which Program did you (youth) sign up for?
First Name *
Youth First Name
Your answer
Last Name *
Youth Last Name
Your answer
Birth Date *
Youth Birth Date
MM
/
DD
/
YYYY
Emergency Contact *
If Youth is yet not 18 years old, provide Guardian's Name
Your answer
Emergency Tel No *
If Youth is yet not 18 years old, provide Guardian's Tel number (with country code)
Your answer
India Contact
Provide Contact name in India. If not, leave blank.
Your answer
India Tel No
Provide tel no in India. If not, leave blank. (without country code 91)
Your answer
Allergies *
List foods & Medications to which you/Youth have allergy. If none, indicate so.
Your answer
Medications *
What medications do you/Youth take regularly? If none, indicate so.
Your answer
Ailments *
What medical conditions / disorders / ailments do you/Youth have?. If none, indicate so.
Your answer
Medical Emergencies *
Do you give permission to treat medical emergencies?
Behaviour *
I/Youth agree to 1) dress appropriately, 2) Not consume meat, any alcohol, tobacco products or recreational drugs, 3) Not to conduct inappropriate behavior, 4) Make any sexual overtures.
Inadequate Facilities *
This program is informal. Institute will make every effort to make it a memorable experience & a great learning opportunity. There may be unavoidable situations such as flooding, loss of electricity, loss of WiFi, appearance of unsolicited insects/creatures in vicinity etc. Additionally, there may be unexpected failures (plumbing, A/C etc.) or accidents. Institute will respond to such situations keeping in mind their criticality but may not be able to resolve in your expected time-frame,. Do you agree to accept inadequate facilities sometimes?
Release of Liability *
I release Muni Seva Ashram, India (MSA) and Muni Seva Charitable Foundation, USA Inc. (MSCF), and their associates, employees and volunteers of any liability for any accidents or injury of any nature or cause including arising from negligence that may occur to me/Youth while attending this camp. Do you agree?
Required
Noncompliance *
I understand and accept that if I/Youth violate any Camp rules or MSA policies, I/Youth may be immediately dismissed from the institute.
Participant Consent *
By clicking here, I agree that I have read and understood all rules and agree to abide by them. If I have not completed 18 years age, I am asking my guardian to answer the next question.
Required
Guardian Consent
The Youth has still not completed 18 years age. I have explained all the rules to the Youth. As his/her Guardian, I agree that the Youth will abide by all the rules.
Arrival date at MSA *
MM
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DD
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YYYY
Departure date from MSA *
MM
/
DD
/
YYYY
Arrival Logistics *
How are you planning to arrive at MSA? (Departure logistics will be addressed after you arrive at MSA)
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