Ph : +91 9816158854 | Ph: +91 9816173988 |   | himalayanwander@gmail.com

MEDICAL FORM

MEDICAL FITNESS CERTIFICATE

(To be filled in by a registered medical practitioner in BLOCK LETTERS)

I certify that I have on this (date)…………….day of(month) ………………, 200….,

medically examined the following person:

Name: …………………….…….………………………………………………..

Son/Daughter/Wife* of ……………………………………………

and/or student of (institution name)……………………………………………….

Age: ………………………., Weight: …………………………………………

Pulse rate: ……………….      Blood Pressure:………………………………….

Blood Test:………………..   Blood Group: ………………………………….

Applicant should not have Asthma, Epilepsy or other fits, and any major deformity, hernia & chronic diseases.

In my opinion, Mr/Miss/Mrs…………………………………………………………………. Whose’s signature is given below is fit to undergo ……………………………………..……. (name

of the camp/trek/tour/safari) being organized by Himalayan Wander,

Manali, Himachal Pradesh, during the period (dates, from/to) ……………………………….

Participant’s Signature: ………………………………………………………………………………………

Address: ……………………………………………………………………………………………

……………………………………….……………………………………………………..

Medical Practitioner’s name in BLOCK LETTERS: ……………………………………..

Professional seal:

Medical Practitioner’s signature: …….……………………………………………………. Address:   ………………………………..…………………………………………………………..

…………………….………………………………………………………………………………….

Date :                                                                                     Place:

Note:

  • The medical practitioner should be M.B.B.S. and give his/her registration No. of medical council.
  • All disputes subject to jurisdiction within Manali only.