South Calcutta Trekkers Association
45B Puddapukur Road, Kolkata 700020 / 14 Chakraberia Lane, Kolkata 700020
(Near Lansdown, Paddapukur, Bhawanipur)
Application Form for 35th Basic Rock Climbing Course 2019
Date : 21st - 24th November, 2019
Field of Training : Susunia Hills, Bankura
Age Limit : 15 - 35 Years

Course fee : Rs. 2600
Minimum Advance : Rs. 1000

** Advance payment is to be made within 15 days of application, otherwise registration will be cancelled


*************** READ THIS FIRST BEFORE PROCEEDING FURTHER ***************

Payment Options:
1. Cash, by hand
2. Online Money Transfer (NEFT/IMPS/UPI)
3. Demand Draft / Cheque Deposit

In case of Online Payment / Cheque Deposit / Demand Draft, make sure you deposit the money first and have the Transaction Reference number / Cheque number ready with you. This form requires those information to be furnished. Else the form can not be submitted.

In case of Cash payment, put "N/A" when Transaction Number is asked.

*************************************************************************************
For any information please call:
Sayantan Dutta : 94336 45889
Barun Mazumder : 79801 42962
Indranil Sarkar : 98742 45190

_______________________________________________________________________________________

Name *
Your answer
E Mail *
Your answer
Date of Birth (put correct year) (Age limit: 15-35 yrs) *
MM
/
DD
/
YYYY
Gender *
Address *
Write Current Address (in full)
Your answer
Contact Number *
Your answer
Academic Qualification
Your answer
Mother-tongue
Your answer
Understand Bengali Language? *
Occupation
Your answer
Hobby / Interest
Your answer
Previous Experience (if Any)
Your answer
Allergy to Drug / Food. If yes please provide details
Your answer
Any chronic disease. If yes, please provide details
Your answer
Food Habit *
Guardian's Name *
Your answer
Guardian's Contact Number *
Your answer
Emergency Contact information *
Write Complete Name and contact number(s)
Your answer
Mode of Payment (Advance amount or Full) *
Amount Deposited *
If you have already deposited the fees, please mention the amount
Your answer
Transaction reference number *
In case of online course fee deposit please provide the reference number. Else put NA
Your answer
Declaration / Risk Certificate
I agree to strictly adhere to the discipline of the program and abide by all the directions of the organizing authorities at all the times during the course *
This is to declare that I am joining the course being aware of the risks of Rock Climbing and I shall not hold the organizers responsible for any ailment, injury or accident beyond their control. *
This is to certify that I am physically fit for undertaking any kind of tough training and that I have not suffered from any infectious disease for last three months. *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service