INDIAN INSTITUTE OF SCIENCE EDUCATION AND RESEARCH KOLKATA

SWIMMING POOL
MEMBERSHIP APPLICATION FORM
For verification of authenticity of the applicant, official records like identity card or health center
booklet and two passport size photographs should be produced at the time of submitting this form.

Category: IISER-K students/ IISER-K Faculty & Staff/ Children/Dependent of employees/ Project
staff/IISER-K Alumni/Retired employees of IISER-K/Guests

Name (IN BLOCK LETTER) _____________________________________ Sex: M/ F, Age ________ Yrs.

Name of the applicant _________________________________________Relation ______________ (In case of

children/spouse or dependents of employees)

Phone No.: __________________________ email address: ___________________________________________

Name of Employee on whom you are dependent (for children/spouse and other dependents)_______________________

Roll No. / EP. No.______________ Designation: ___________________ Department: ___________________

Address: ________________________________________________________________________________________

Name & address of person to be contacted in case of emergency: _________________________________________

_________________________________________________________________ Phone No.: ____________________

Resident Non Resident

Preference of Slot: ____________________

Swimmer Non Swimmer

DECLARATION
1. In case of an Accident I will not hold the institute authorities responsible in any way. Rules &
Regulations and their amendments as decided by the Swimming pool management committee are
applicable on me and I agree to abide by them. I shall cooperate with the authorities in maintaining the
discipline in the swimming pool.
2. I declare that I am not suffering from any communicable disease, Epilepsy and Psychiatric Illness.
3. I understand that if any one of the details given above is proved to be false, my membership will be cancelled and
suitable disciplinary action will be taken against me.

(Signature of the Employee)

(In case of children or dependents of employee) (Signature of the Applicant)

Date: _________________ Date:_________________