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Ph. : 01334: 244107, 240008, 246737

Fax : 01334 –244805
e-mail : divyayoga@rediffmail.com
visit us : www.divyayoga.com
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PATANJALI YOGPEETH (TRUST)

Contact Office : Maharishi Dayanand Gram, Delhi-Haridwar National Highway,
Near Bahadrabad, Haridwar-209402

Performa For Registration In Residential Yog-Science Camp

(Please read carefully all rules and regulations for the registration, before filling the form) Paste
Category Stamp-Size
(i) V.V.I.P. Category With A.C. Suite Residence. ( ) Photograph
(ii) V.I.P. Category With A.C. Room Residence. ( )
(iii) General Category With Non A.C. Room Residence. ( )
(Tick the category in which you want to participate)
Camp From --------------------------------- to ---------------------------------.
Description of Donation

I- Name of Issuing Bank with Station -------------------------------------------------------------------

II- D. D. No. ----------------------- Date ----------------- Amount ---------------------------------------
III- Drawn on -------------------------------------------------------------------------------------------------
IV- Receipt No. ------------------ -- Date --------------------------------------(Filled Up by the office)
Participants Particulars
Name of Participant ----------------------------------------------------------------------------------------------------
Gender : ( ) Male ( ) Female (Tick which is applicable)
Father’s/Husband’s Name ---------------------------------------------------------------------------------------------
Postal Address ----------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------
Phone Nos. with S.T.D. I- Residence-------------------------------II- Office -------------------------------------
Mobile Nos.--------------------------------------------------------------------------------------------------------------
Marital Status I- ( ) Married II- ( ) Unmarried (Tick, which is applicable)
Age ------------------ Education ---------------------- Occupation --------------------------------------------------
Height --------------- Weight --------------------------Hobby -------------------------------------------------------
Detail of persons who got registered as participants in camp and take part with you :-
I- Name ----------------------------------------------------Relation with you ----------------------------
II- Name ----------------------------------------------------Relation with you ----------------------------
(Attach separate sheet for more persons)
Name of Disease, you have -----------------------------------------------(Attach recent pathological report
pertinent to your disease).
Is it hereditary? ( )Yes ( ) No (Tick, which is applicable)
Do you addict to ?
I- ( ) Tea/Coffee II- ( ) Alcohol III- ( ) Smoking IV- ( ) Tobacco/Gutka V-( ) Non Vegetarian
(Tick, which is applicable)
Your purpose of learning Yog ----------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------

Declaration
I, hereby, declare that I read all rules and regulations concerned for the registration in the residential
yog camp, I shall abide by all the rules and regulations concerned. In the event of violation of rules and
regulations concerned, by me, the trust is independent to take any disciplinary action against me and I
shall be entirely responsible for it.

Signature of Participant
------------------------------------------------------------------------------------------------------------------

Permission of Entry in Residential Yog-Science Camp

Entry No. ----------------------

Sh./Smt//Ku. ---------------------------------------- S/o/W/o/D/o ----------------------------------is allowed to

participate in the residential yog camp held from ----------------------------- to ----------------------------- in
i- V.V.I.P. Category With A.C. Suite Residence ( ), ii- V.I.P. Category With A.C. Room
Residence ( ), iii- General Category With Non A.C. Room Residence ( )

Signature of Camp-Coordinator