EARTH JOURNEYS
REGISTRATION FORM
Name (in block letters) Surname (in block letters)
Mr / Ms ______
Date of Birth Date ____ Month ____ Year _____
Mailing Address: ______
______
Telephone: ______E-mail : ______
Permanent Address: (if different from above)
______
______
Telephone: ______E-mail : ______
Occupation
Indicate the Earth journey you are applying for (Please tick √)
1) Earth Journey to the Himalaya : February 2015 (8-16th Feb. 2015)
2) Earth Journey to Ladakh August 2015 (11th - 20th Aug. 2015)
3) Earth Journey to the Heart of India October 2015 (1st - 8th Oct. 2015)
4) Earth Journey to the Heart of India: Bundelkhand February 2016
5) Odisha March - April 2016
6) Rajasthan - Oct 2016
Person to be contacted in Emergency
Name Telephone Number
Mailing Address E-mail
Please specify if you have health insurance
Educational qualification / special skills / areas of interest (eg. trekking, mountaineering etc. )
Write a few sentences about yourself.
What organizational affiliation do you have?
Have you been associated with Bija Vidyapeeth (or Navdanya, the Research Foundation for Science, technology and Ecology or Diverse Women for Diversity) earlier? (please indicate how)
What are your expectations from this Journey?
How did you come to know about Earth Journey?
______
Earth Journey Policy
Registration will be confirmed after the receipt of 50% of total fee registration.
Cancellation
25 % of the fee will be deducted if cancelled 3 weeks before departure.
35 % of the fee will be deducted if cancelled 2 weeks before departure.
100 % deduction within 1 week or less before departure
In the event that the program is called off by Navdanya Earth Journeys 100% refund will be provided to the participant.
Payment Modes
Registration fee : 50% in advance either through DD/Bank Transfer.
Payment should be made in the form of bank demand drafts in favour of Navdanya Trust.
We also accept credit card/ cash payments at the Dehradun/ Delhi office
For online transfer please get in touch with ,
Documents
Following documents (scanned/Photocopy) are mandatory with the application form:
For Indians / Nepalese and Bhutanese: Identity proof
For Foreigner : copy of passport & valid Visa
For more information please contact , , 0135 2693025 or visit www.navdanya.org
Participant Health Statement & Authorization for Medical Treatment
Please complete the following as thoroughly as possible. All material is confidential. The information will be used only by the program leaders and any emergency medical personnel.
______
HEALTH QUESTIONAIRE:
What physical disabilities or conditions (heart conditions, diabetes, seizures, etc.) do you have that might affect your participation in this activity including operations illness, broken bones in the past six months? ______
Any allergies, specifically bee stings, food, or medications /drugs? ______
______
Last date of immunization (tetanus, booster, etc.)? ______
List any medications being taken? ______
______
Name of family physician ______
Contact Number of physician: ______
PERSON TO CONTACT IN CASE OF EMERGENCY:
Emergency Contact: Name ______
Relationship ______
Phone (home) ______(work) ______Email: ______
Address ______
______
In the event that I am rendered unable to communicate due to illness, accident, or emergency while participating in the Navdanya Earth Journey, I hereby give permission to the Physician, selected by Navdanya Earth Journey personnel, to hospitalize, secure proper treatment for, and to take whatever medical actions necessary to treat me.
Signature f Participant ______Date______
Parent/Guardian Signature if under 18 years of age ______
RELEASE OF LIABILITY AND ASSUMPTION OF RISK
This form is to be read and signed by the candidate or by his / her parents / guardians on behalf of the participant attending and/or participating in an Earth Journey.
Before agreeing to take part in Earth Journeys organised by Navdanya I agree and state as follows:
I am familiar with and will obey any and all of the rules, written and spoken, established for the Navdanya Earth Journey.
I understand and appreciate the inherent risks and dangers of participating in the journey , accidents or illnesses occurring in remote places without medical facilities and travel by, automobile and or other forms of transportation, which could result in damage to property and personal injury; and I agree to accept all risks whether present or future, known or unknown, arising from or as a result of my participation in these activities.
I SHALL HOLD HARMLESS AND INDEMNIFY Navdanya Earth Journey and its officials, administrators, employees and all sponsors and individuals assisting in the presentation of the, Navdanya Earth Journey, owners of the property on which the Navdanya Earth Journey is held for any liability and all claims of damages, demands and actions whatsoever in any manner resulting from my participation in this program/activity.
I understand that Navdanya Earth Journey activities are facilitated by qualified full-time/part-time facilitators.
I understand I must be healthy and reasonably fit in order to safely participate in the Navdanya Earth Journey and, that I will inform the program/activity leader of any medication, ailment, condition or injury that may affect my performance or reasonably preclude me from participating; and
I state that I have read, understand and agree to all conditions set forth herein and that i sign voluntarily.
Traveler's Guide
As a traveler, you will have an impact on the environment and culture of the place you are visiting. Here are some rules of thumb to make this impact positive!
Do's
Please carry back all non-degradable litter such as empty bottles, tins, plastic bags etc. You must not litter the environment. Biodegradables should be buried. Other items must be disposed in dustbins only.
Observe the sanctity of holy sites, temples and local cultures.
Cut noise pollution. Do not blare aloud radios, tape recorders or other electronic entertainment equipment
Respect people's privacy while taking photographs. Ask for prior permission before taking a photograph.
Don'ts
Do not take away flora and fauna in the forms of cuttings, seeds or roots. It is illegal, especially in the Himalaya.
The environment is really delicate in this region and the bio-diversity of the region has to be protected at all costs.
Do not consume aerated drinks, alcohol, drugs or any other intoxicant and throw bottles in the wild.
Do not tempt the locals, especially children by offering them foodstuff or sweets. Respect local traditions.
Polythene and plastics are non biodegradable and unhealthy for the environment and must not be used and littered.