Card No.
_________ Indian Institute of Technology Kanpur
Physical Education Section
Old Sports Complex Photo
OSC GYMNASIUM MEMBERSHIP FORM
For verification of authenticity of the applicant, official records like identity card of health center
booklet along with one passport size photograph should be produced at the time of submitting this
application form.
Category: IITK Student/ IITK Faculty/ Staff/ Children/ Dependent of an employee & Students/ RA/
Project Staff/ Employee of campus organization/ IITK Alumni/ IITK Retired Employee.
Type of membership: Monthly/ Summer/ Semester I/ Semester II/Annual/ Weekly Guest Pass.
Name (IN BLOK LETTER) __________________________________________________________ Sex: M/F, Age: ________ Yrs.
Name of the employee______________________________________________________________ Relation ____________________
(In case of dependent of an employee)
Roll No./ P.F. No. ____________________ Designation: ____________________________ Department: ____________________
Campus Address: __________________________________________________________________ Phone No. ___________________
Name and address of campus resident to be contacted in case of emergency: ________________________________
______________________________________________________________________________________ Phone No. ___________________
Preference of Slot: _______________________________
Fee Structure for Old Sports Complex Gym: -
Category Monthly Semester Summer Yearly Weekly Guest
Students 350 1300 650 2300 350
Staff & Project 450 1650 800 2900 450
Faculty 550 2000 1000 3500 550
DECLARATION
1. In case of an accident, I will not hold the institute authorities responsible in any way.
2. I will abide by the following rules:
(i) Member should bring clean shoes to be used exclusively for the gym and the same must
be worn in the cleaning room before entering the gym.
(ii) Member should wear proper sports sear: T-shirts/shorts/Lower/shoes.
(iii) The Member should bring membership card, sanitizer & hand towel at the time of
doing gym.
3. Other Rules & regulation and their amendments as decided by the SPEC are applicable on me and I
agree to abide by them. I shall cooperate with the authorities to maintaining the discipline in the
Gymnasium.
4. I understand that if any one of the details given above is proved to false, my membership will be
cancelled, and suitable disciplinary action will be taken against me.
________________________________ ___________________________
(Signature of the Employee) (Signature of Applicant)
(In case of dependent of an employee)
Date: ____________________
RECEIPT
Received a sum of Rs. ___________ Rupees ______________________________________________) from Miss/ Mr./ Dr.
___________________________________________ as Monthly/Semester/Summer/Annual/ Weekly Guest Member
subscription for Old Sports Complex.
