DIVYA SAMAJ KA NIRMAN (DSN)
REGISTRATION FORM
Vyakti Vikas Kendra, India, No. 19, 39th A Cross, 11th Main, IV T Block, Jayanagar, Bangalore – 560 041
Amritsar Information Centre: Majitha Rd., Amritsar (9878001248,9855044460)
Date of Course :10 Jul’08 (Reporting Time: 5:00 PM) to 14 Jul’08
Name: _______________________________________ Male [ ] Female [ ]
Home Address: _____________________________________ Married [ ] Unmarried [ ]
_____________________________________________________________________________
Phone (Res.) _____________ (Off.) ___________ (Mobile) ___________
Email: _______________________________
Date of Birth: ___________ Educational Qualification: _________________________________
Profession: [ ] Medical [ ] Engineering [ ] Business [ ] Govt. Service – Position _________
Others: Please specify __________________________________________________________
1. Are you experiencing any of the following health conditions?
Asthma [ ] Epilepsy [ ] High Blood Pressure [ ]
Heart Problem [ ] Back Pain [ ] Pregnancy [ ] Schizophrenia [ ]
Others (Please specify): _______________________________________
2. Are you currently taking any prescribed medication?
Yes [ ] No [ ] If yes, please explain ___________________________
3. Have you ever undergone psychiatric treatment before?
Yes [ ] No [ ] If yes, please explain ____________________________
4. Details of Part-I Course:
Name of Teacher ____________________ Place__________________________________
Date of Course ____________________
5. Accommodation Required?
Yes [ ] No [ ]
6. Course Contribution.
Non Residential Rs.2400/- [ ] Residential Rs.3000/- [ ]
Personal Donation for the Course, Rs. __________
Mode of payment: Cash / DD no. / ____________ drawn on ____________ Bank, dated _______
In favor of VVKI-Punjab Apex Body, payable at Hoshiarpur (Punjab)
Declaration
I understand that any benefits derived from this course depend upon the extent of my participation. I therefore, accept full responsibility for the outcome. I willingly agree to follow all instructions and commit myself to attend all sessions without any exception. I also agree that I will not disclose the contents of this course to anyone. I declare that I am physically and mentally able to participate in this programme.
Place: ....................................
Date: Signature