GUJARAT NARMADA VALLEY FERTILIZERS & CHEMICALS LTD. SPORT & RECREATION CLUB & COMMUNITY WELFARE APPLICATION FORM FOR-SWIMMING POOL MEMBERSHIP To, EC No, :____ DATE: Manager ENTRY ‘Sport & Recreation Club & Community Welfare PASS NO. GNFC Ltd, P.O. Narmadanagar-392015 Dist : Bharuch Dear Sir, I/we hereby apply for the membership of the swimming Pool. live declare that my / our parents have no objection of my / our becoming member of the swimming pool and in case of any mishaps the responsibility is solemnly mine / ours. | am /we are not suffering from any contagious diseases which may endanger my life or of other persons using the swimming pool. | / we further declare that, I/we am / are not suffering nor have | / we suffered in past from Hysteria, Gas, Diabetes or any other diseases which may cause sudden pain while Swimming I/We have read the rules & regulations of Swimming poo! and agree to abide by the same. Following are my / our particulars : 1) Name in full in capital letter 4) (Begining with surname) of - 2) Self & Dependent 3) 4) 2) Address & Phone No. 3) Age & Birthdate 1) Of Self & Dependents 2) 3) 4) 4) — Parents full name, address & Signature of the parents Ifthe applicant is Minor Giving his / her consent | 5) Swimmer/Leamer 1) ___2) _______3) ______4) 6) Coach signature for verification of Swimmer / Learner 1) _____2) ______3) ___4)___ 7) Membership (with Date) Monthly : Yearly Place Signature of Applicant 1) __2)__3)__4) With name(To be signed by Medical Officer) This is to certify that Shri / Smt. / Kumari is Physically i for swimming and is quite free from any contagious disease, epilepsy or lke discase which may endanger his / her health or life or adversely affect health of other persons using the swimming pool or may cause to him/her any accidental pain while swimming, a Signature of Doctor Place: ______ Qualification & Address Stamp (To be signed by Medical Officer) This is to certify that Shri / Smt. / Kumari is Physically fit for swimming and is quite free from any contagious disease, epilepsy or like discase which may endanger his/her health or life or adversely affeect health of other persons using the swimming pool or may cause to him/her any accidental pain while swimming Date ;—_____ Signature of Doctor Place: __ Qualification & Address Stamp (To be signed by Medical Officer) This isto certify that Shri / Smt. / Kumari is Physically fit for swimming and is quite free from any contagious disease, epilepsy or like discase which may endanger his/her health orlife or adversely affeect health of other persons using the swimming pool or may cause to him/her any accidental pain while swimming. Date: ‘Signature of Doctor Place: ___ Qualification & Address Stamp (To be signed by Medical Officer) This is to certify that Shri / Smt./ Kumari is Physically fit for swimming pool and is quite free from any contagious disease, epilepsy or like discase which may endanger his / her health or life or adversely affeect health of other persons using the swim- ming pool or may cause to him/her any accidental pain while swimming, Date: ____ ‘Signature of Doctor Place: __ Qualification & Address Stamp