Note : All * are mandatory fields

PARTICIPANT PROGRAM DETAILS

First Name*

Gender*

School

Residential Address




Email Id

Star*

Last Name*

Date of Birth*  

Class

City*

Pin*

Mobile

Program *

Major Activity*

Upload Photo of your current School Id Card Photo (Size : 200kb)





Veg/NonVeg Height (When choosing mountain biking) Inch

PARENT'S DETAILS

Father's First Name *

Father's Last Name*

Organisation

Designation

Mobile *

Email *

Mother's First Name*

Mother's Last Name*

Organisation

Designation

Mobile*

Email*

OTHER DETAILS

Have you been to Youreka before? * Yes   No
If yes, when?
Ex:2017,2016,2015
If you have been referred, please write his/her Name and Mobile No.

MEDICAL DETAILS

Blood Group
Motion Sickness?

1. Please state clearly if there is anything you wish the campus doctor should know regarding your child’s health and medical needs

2. Please specify if your child is allergic to any substances, food or medicines. What remedial action do you adopt in case of the allergy? *

3. Has the child been hospitalised in the past year? If yes, provide details on a separate sheet *

4. Does your child suffer from asthma or epileptic fits? If yes, please provide the prescription of medicines by your physician. *

5. Has your child suffered from any muscle / bone/ ligament related problems or recent fractures, if any. *

6. Does your child sleep walk or has bed wetting problem? *

7. Does your child have a valid anti-tetanus shot? If No, please get the shot before the camp. *

8. If your child is using any medication, please mention this and ensure that it’s carried to the programme.

9. In case we need to contact your family physician/doctor, please provide the details.

10. Does your child wear prescription glasses? If Yes, Please pack an extra pair. *

NOTE : If required, details filled in the form also gives the physician, selected by Youreka, permission to hospitalise or provide medical treatment to your child. (Please use an extra sheet if you wish, to bring anything to the notice of the campus doctor)

Contact:
We will also send you 3 SMS updates about your child during the course of the campout. Please write the number you would like us to use for messaging :*  

Parent Consent

(NOTE: Submission of this form does not guarantee a seat, till payment is made.)