ʻRESCUE INDIA 2017ʼ
RASHTRIYA LIFE SAVING SOCIETY (INDIA) NATIONAL HEADQUARTERS, PUNE
B4/101, Lunkad Daffodils, Viman Nagar, Pune. Pin: 411014 Tel. no.: 020 65600575
‘RESCUE INDIA 2017’ NATIONAL LIFESAVING POOL, BEACH & OCEAN CHAMPIONSHIP Venue: Campal, Goa & Malvan, Maharashtra, India OFFICIAL
Please attach ID size photo with full name written behind
/ VOLUNTEER
Name Mr. / Ms. _______________________________________________________________________________________________________________ Date of Birth: ________/__________/_____________________ Age : ______________________________
M/F________________________
Representing State:____________________________________________ City:__________________________________________________________ Phone No(s): Mobile No: ____________________________________ Whatsapp No.: ________________________________________________ E Mail ID: ______________________________________________________________________________________________________________________ Organization/ Club: __________________________________________________________________________________________________________ Mailing Address of the Individual: ____________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ___________________________________________________________________________________PIN CODE__________________________________
I AM INTERESTED TO OFFICIATE/ VOLUNTEER FORPOOL EVENTS
BEACH EVENTS
OCEAN EVENTS
I AM A (Tick if applicable) 1. Life Saver 2. Life Guard 3. Swimmer 4. Coach/ Team Manager 5. Individual (If Available) RLSS (I) Membership No*: ________________________Valid till *:_______________________________________ Any other/special/technical qualification:_____________________________________________________________________________________ Stamp & Sign of Club / Organization / SLTC / District: _______________________________________________________________________
I hereby state / declare that I am participating in this event at my own wish, cost, risk and consequences and therefore I will not hold anyone else (Organization, Institution or Individuals) responsible in any manner, in case of an injury, accident including temporary / permanent disablement or loss of life which may occur during or after the above event. I accept that the organizing committee’s decision and arrangements for the event will be final and binding on me. Any personal expenses/costs during the event shall be borne by me. My Travel DetailsArrival at venue (Pool/Ocean) Date______________________ /
Mode of travel to venue: Bus/Train/Flight/
Traveling from _________________________
Departure from venue(Pool/Ocean) Date______________________ /
Place:_____________________
Mode of travel to venue: Bus/Train/Flight/
Traveling from _________________________
Signature ____________________________________
B4/101, Lunkad Daffodils, Viman Nagar, Pune. Pin: 411014 Tel. no.: 020 65600575
‘RESCUE INDIA 2017’ NATIONAL LIFESAVING POOL, BEACH & OCEAN CHAMPIONSHIP Venue: Campal, Goa & Malvan, Maharashtra, India OFFICIAL
Please attach ID size photo with full name written behind
/ VOLUNTEER
Name Mr. / Ms. _______________________________________________________________________________________________________________ Date of Birth: ________/__________/_____________________ Age : ______________________________
M/F________________________
Representing State:____________________________________________ City:__________________________________________________________ Phone No(s): Mobile No: ____________________________________ Whatsapp No.: ________________________________________________ E Mail ID: ______________________________________________________________________________________________________________________ Organization/ Club: __________________________________________________________________________________________________________ Mailing Address of the Individual: ____________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ___________________________________________________________________________________PIN CODE__________________________________
I AM INTERESTED TO OFFICIATE/ VOLUNTEER FORPOOL EVENTS
BEACH EVENTS
OCEAN EVENTS
I AM A (Tick if applicable) 1. Life Saver 2. Life Guard 3. Swimmer 4. Coach/ Team Manager 5. Individual (If Available) RLSS (I) Membership No*: ________________________Valid till *:_______________________________________ Any other/special/technical qualification:_____________________________________________________________________________________ Stamp & Sign of Club / Organization / SLTC / District: _______________________________________________________________________
I hereby state / declare that I am participating in this event at my own wish, cost, risk and consequences and therefore I will not hold anyone else (Organization, Institution or Individuals) responsible in any manner, in case of an injury, accident including temporary / permanent disablement or loss of life which may occur during or after the above event. I accept that the organizing committee’s decision and arrangements for the event will be final and binding on me. Any personal expenses/costs during the event shall be borne by me. My Travel DetailsArrival at venue (Pool/Ocean) Date______________________ /
Mode of travel to venue: Bus/Train/Flight/
Traveling from _________________________
Departure from venue(Pool/Ocean) Date______________________ /
Place:_____________________
Mode of travel to venue: Bus/Train/Flight/
Traveling from _________________________
Signature ____________________________________
