Vyakti Vikas Kendra, India

No. 54, 39th A Cross, 11th Main, IV T Block, Jayanagar, Bangalore: 560 041

YOGATHON REGISTRATION FORM

(Please write clearly and in BLOCK LETTERS. All information in this application will be kept strictly confidential) Name of the Institution: ________________________________________________________________________ Name of the individual: ____________________ Male [ ] Female [ ]

Designation: _______________________________________ Company Address: _____________________________________________________________________________ _____________________________________________________________________________________________ City/Town: _____________________ PIN Code: _____________________ State: __________________________ Office Phone: Landline: ________________ 1. Mobile: (Individual): ______________________

How many employees do you have in your organization? 6 x 3 feet of space)? Y / N

2. Would you have sufficient space for everyone to do the Surya Namaskar (Each person will require 3. How many of them would like to register for the Yogathon Challenge (Please specify Nos.____)
and how many of them would like to register for the Dream Run (Please specify Nos._____)

4. Would you like one of our representatives to contact you for further discussion? Y / N
5. How did you come to know about YOGATHON? Friends & Relatives [ ] Newspaper Ads/TV [ ] Leaflets/Books/Talks [ ] E-mail/Brochure [ ] Web [ ] Presentation [ ] Physical Fitness Analysis (this analysis would need to be carried out for all your employees who wish to Participate in the Yogathon event) a. Are you experiencing any of the following health conditions* Asthma [ ] Breathing Problems [ ] Diabetes [ ] Spinal/Back problems [ ] Epilepsy [ ] Heart Disease [ ] High Blood Pressure [ ] Pregnancy [ ] High Cholesterol [ ] Schizophrenia [ ] Hernia [ ] others (Please specify): ___________________________________________________________________________________ b. Are you currently taking any prescribed medication? Yes [ ] No [ ] If yes, please specify ___________________________________________________________________________________

6.

c. Have you ever undergone any psychological/psychiatric treatment before?

Yes [ ] No [ ] If yes, please specify ___________________________________________________________________________________

d. Have you ever undergone any surgery in the past? Yes [ ] No [ ]

If yes, please specify ___________________________________________________________________________________ * People with specific health conditions as mentioned above should consult a doctor before participating in this event. Declaration I understand that the result of this event depends upon the extent of my participation. I therefore, accept full responsibility for the outcome. I willingly agree to follow all instructions and commit myself to attend this event without any exception. I release Vyakti Vikas Kendra, India (VVKI), all organisors, assistants & volunteers from all damages whatsoever and waive the right to compensation in case of any mishap or injury. I declare that I am physically and mentally fit to participate in this event.

Place: ________________________ Date: ____________ Signature: _____________________________