APPLICATION FORM

Name :*
Dath of Birth:*
Gender :
Male
Female
Occupation :
Company Name :*
Postal Address :*
City :*
Country :*
Nationality :*
District :*
Zip / Pin Code :*
State :*
Email :*
Mobile No. :*
Languages known :
English
Others :
How did you hear about us? :
Would you like to volunteer for :
General organizing
Trek
First Aid
Music / Bhajan
Highlight the Yatra-India Programs attended so far :
None of the Yatra-India programs taken yet
Yatra-India Yoga
Yatra-India Inner Engineering
Wholeness
BSP
Samyama
Others
Person to contact in case of emergency :
Name :
Relationship :
Postal Address :
City :
District :
Zip / Pin Code :
State :
Country :
Email :
Mobile :
Phone No. :
Medical Information :
A -
Blood Group
Height
Weight
B - Do you presently have or have ever had any of the medical conditions listed below? If so, please tick applicable & provide complete details (if necessary, provide details in separate sheets and submit copies of relevant records along with this form)
Medical Conditions
If applicable, please provide complete details
Swelling of both feet
No
Transient loss of consciousness on & off
No
Breathing Difficulty
No
Chest Pain on climbing stairs / walking on flat surface
No
Palpitations
No
High BP
Low BP
No
Diabetes
Impaired Glucose Tolerance
No
Heart Problems since birth
Heart Attack
Failure
Oprations
No
 
 
Asthma
Sinusitis
Tuberculosis
Bronchitis
Persistent Cough
Lung Disorders
No
 
 
 
 
Stroke
Fits
Neurological Problems
No
Depression
Mental Disorders
Anxiety
Treated by Psychiatrist
No
 
 
Arthritis
Varicose vein
Back pain
Joint mobility problem
No
 
Any Physical Deformity
No
C - Have you suffered any other illness NOT mentioned above? If yes, please give details
D - Are you currently taking any medication for treatment of a medical condition? If yes, list name, dose and duration of the medicines.
E - Do you smoke; consume Alcohol / Tobacco products / Addictive Drugs or Narcotics such as cocaine, heroin, etc on a regular basis?
Yes
No (If 'Yes', please Give details) :
 
 
Note: This Yatra-India is not advised for pregnant women and those suffering from chronic health problems like epilepsy, heart ailment, psychological problems and physical disabilities
Declaration by the participant:
I, ............................................................................... hereby willingly undertake to attend this 'Yatra-India' for my well-being at my own risk and will not lay blame under any circumstances for any loss, damage or possible injuries to person or property. I further indemnify Yatra-India against all claims and suits and state that my legal heirs shall also not lay any claim against Yatra-India in this regard. Furthermore I state that I have undertaken a recent full medical examination and take full responsibility for my physical condition. I confirm that Yatra-India will bear no liability should any medical matter arise during this Yatra-India and that I shall be financially responsible for any consequential medical expenses.
I confirm that all information provided is true and accurate and agree to it being shared with Yatra-India. I acknowledge the Yatra-India's terms and conditions.
I have understood the contents translated and read to me in a language that I fully understand.
By submitting this form, I agree to the Terms and Conditions mentioned below : 
I understand that the Yatra-India trip is challenging, in a variety of ways, including but not limited to the nature of the accommodations, the weather conditions, the size of the group and the journey itself. On this trip, I may be exposed to certain known and unknown risks, dangers, hazards and liabilities. In particular, I understand that there are certain risks inherent with this trip, including but not limited to the possibility of medical complications arising from the altitude, weather or travel conditions. I affirm that I am in good health and capable of performing whatever physical exercise or activity is required of me.�I freely accept and fully assume any legal responsibility for any personal injury, death, losses, inconvenience or property damage that may arise from such risks, dangers and hazards as a result of my voluntary participation on this trip.
I hereby agree to follow all rules, regulations, and instructions of the trip organizers while on this trip. I understand that the itinerary for this trip and the travel details are subject to change by the organizers, as needed to further the interests of the travel group at large.�Yatra-India has organized this trip on the clear understanding that it shall not be, in any way, responsible or liable for any accident, damages, loss, delay, international flight cancellation/delays, or inconvenience caused in connection with the travel facilities arranged.
I agree to unconditionally abide by any decision Yatra-India may take in the event the trip be rendered impossible, due to unforeseen acts of nature, or any other unforeseen event or incident that renders it impossible for the travel group to make or continue the journey or if I am required to drop from the trip due to any act or omission on my part which in Yatra-India's view would amount to breach of the travel code of conduct, whether explicit or implied. Yatra-India's decision in this regard shall be final and binding. Yatra-India reserves the right to modify any arrangements required by and made on behalf of the participants and to cancel the same without prior notice due to unforeseen circumstances.
I understand that as this is a trip that is spiritual in nature, I may be asked to refrain from certain activities or follow certain prescribed spiritual practices; I agree to make my best effort to follow the recommended schedule and practice guidelines. I understand that as my experience will vary on numerous factors including my own actions; I cannot hold Yatra-India, its volunteers, agents or those in active concert with them liable should I not be satisfied with my experience of this trip.
In consideration of Yatra-India allowing me to participate in this trip, I, on behalf of myself, my heirs, executors, administrators and assigns, hereby release, discharge, indemnify and hold harmless Yatra-India, its officers, directors, employees, servants, agents and volunteers and each of their heirs, executors, administrators and assigns from any claim, cause of action, costs, attorneys fees, expenses or demands and all liability whatsoever arising or that may arise as a result of my participation in this trip due to any cause whatsoever, including negligence, breach of contract, or breach of any statutory or other duty of care, on the part of Yatra-India, and further including the failure on the part of Yatra-India to safeguard or protect me from the risks, dangers and hazards of the trip. Should emergency medical services become necessary for the undersigned participant, the expenses are the sole responsibility of the participant and not that of Yatra-India.
I hereby agree that Yatra-India may use film or photographic records of this trip for its promotional and/or commercial purpose.
This agreement shall be governed by and interpreted solely in accordance with the laws of India and no other jurisdiction. Any litigation involving the parties to this Agreement shall be brought solely within the state of Tamil Nadu, India and shall be within the exclusive jurisdiction of the courts of India.
I CONFIRM THAT I HAVE READ AND UNDERSTOOD THIS AGREEMENT PRIOR TO SIGNING IT/THIS AGREEMENT HAS BEEN READ OVER AND EXPLAINED TO ME IN A LANGUAGE I UNDERSTAND PRIOR TO MY SIGNING IT, AND I AM AWARE THAT BY SIGNING THIS AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS, AND REPRESENTATIVES MAY HAVE AGAINST Yatra-India.

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