First Name: *
Last Name: *
Postal Code: *
Home Phone: *
Email Address: *
Date of Birth: *
High School Student College Student Graduate Student Employed Unemployed
Required if you are UNDER 18 years old.
Father's Work Phone:
Father's Cell Phone:
Mother's Work Phone:
Mother's Cell Phone:
Parent's Address :
Have you attended Sidak before? *
If yes, in which program did you participate?
Sikhi 101 Sikhi 201 Gurmukhi 101
Gurmukhi Script Skills (check one): *
None Extremely Limited Read & Write
Panjabi Language Skills (check one): *
None Extremely Limited Understand & Speak
Will You Be Applying for Junior Sidak?
Acceptance into the program will be determined largely by the responses to the below questions. Therefore, please answer thoroughly and use as much space as necessary.
How did you hear about Sidak? *
Please tell us about your past and present involvement with the Sikh community and Sikhi-related activities: *
Why do you want to attend Sidak? *
In what areas of Sikhi do you feel you most need to grow and learn? What are your expectations of the program? *
How would you like to apply what you learn at Sidak when you return to your home and communities? *
Any other considerations you would like to bring to the organizer’s attention? *
The information in this section is not part of the participant acceptance process. It is gathered to assist in identifying appropriate care for each participant. All medical information is confidential. IF THE APPLICANT IS A MINOR, THIS FORM MUST BE COMPLETED BY A PARENT OR GUARDIAN. Any changes to this information that occurs between submission of this form and commencement of the correlating event should be provided to SikhRI prior to the applicant's involvement in the program. Please make sure to provide detailed and accurate information so Sikh Research Institute is aware of your/your child's needs.
Primary Physician's Name: *
Physician's Phone : *
List any dietary restrictions:
Please list all known allergies, describe reaction and its medical solution
Please list all medications (including over-the-counter and nonprescription drugs) taken routinely. Make sure to bring enough medication to last for the duration of the program. Keep medication in its original packaging that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.
Will you be taking any prescribed medication during the program? *
If yes, please provide the information on medication, dosage, specific time it needs to be taken and the reason for taking it:
Do you have any of the following medical conditions? (Check all that apply):
Asthma Allergies Convulsive Disorders HIV Positive Heart Problem Pulmonary Disorders Muscular-Skeletal Disorder Diabetes Mellitus Hepatitis Oitus Media Skin Infection Neurological Disorder Epilepsy
Other issues Sikh Research Institute should be aware of? (Please elaborate) :
Do you have any physical limitation that might restrict participation in program activities? *
If yes, please explain:
Have you required medical treatment for an injury within the last year? *
If yes, please explain (1):
Have you received any treatment for any medical or psychological condition within the last year? *
If yes, please explain (2):
Is the applicant covered by family medical/hospital insurance? *
If yes, the insurance carrier/plan name:
Group Number :
Insurance Address :
Name of policyholder (if other than applicant):
Relationship to applicant:
SSN of policyholder or insurance ID:
First Emergency Contact : *
Relationship to Applicant: *
Emergency Contact Phone: *
Second Emergency Contact: *
Relationship to Applicant (2): *
Emergency Contact Phone (2): *
EMERGENCY RELEASE AGREEMENT:
Permission to provide necessary treatment or emergency care: In the case of an accident or illness that requires emergency medical care, I hereby give permission to the attending (licensed) medical personnel to order such medical attention as may be deemed necessary for the health and safety of me/my child. In the event that I am not responsive or a parent or guardian cannot be reached in an emergency, I hereby give permission to the physician selected by the Sikh Research Institute to secure and administer treatment, including hospitalization, for the person named above. The medical information above is complete and accurate to the best of my knowledge.
I DO consent or agree to the emergency release terms mentioned above. I DO NOT consent or agree to emergency release terms mentioned above.
PROGRAM FEES AND PAYMENT:
Total Program Fees: $850 (US)
Non-refundable application fee of $100: Due at time of application
Acceptance deposit of $375: Due by 30 June 2013
Remainder of Program Fee ($375): Due upon arrival to Sidak
If you wish to be considered for a waiver for all or a portion of the fee, please answer the following questions.
Applications for fee waivers will be accepted up until the application deadline. Completed applications will be considered on a first come, first serve basis while funding is available.
Amount of Fee Applicant Can Pay:
Travel Expenses (Note: SikhRI does not cover travel costs associated with attending Sidak):
Please explain any unusual expenses, other debts, or special circumstances that SikhRI should consider in consider.:
I understand that the Sidak program is an intensive two-week learning experience.
I certify that the information provided in this application is true and complete.
I certify the health history is correct and complete as far as I know.
I understand that completion of this application does not guarantee acceptance into the program. The Sikh Research Institute will have the sole authority to make the final selection of program participants. I understand that any false answers of statements or misrepresentations by omission made by me on this application will be sufficient reason for the rejection of my application or for my immediate discharge from participation in a program.
I recognize my personal responsibility to fully engage myself in the program. I agree to comply with all applicable policies, procedures, and rules of the Sikh Research Institute, and I understand that any violation may result in my immediate dismissal from the program. If I am dismissed for any reason, my parents/guardian will be notified and will be responsible for arranging transportation and covering the costs associated with sending myself/my child home from the program site.
I assure you that I/my child have no known mental or emotional disorders or sensitivities that would interfere with my/my child's participation.
I understand that although the Sikh Research Institute has taken precautions to provide proper organization, supervision, instruction, and equipment for each activity, it is impossible for Sikh Research Institute to guarantee absolute safety. I also understand that each participant shares the responsibility for safety during all activities, and I assume that responsibility for myself/for my child. I waive any claim that may arise against the Sikh Research Institute and/or its Board of Directors, employees, volunteers, or lessors including those claims that may arise from negligence of the Sikh Research Institute, and/or its Board of Directors, employees, volunteers, or lessors.
If the Sikh Research Institute must send me/my child home for any reason, I agree to arrange transportation and cover the costs associated with sending her/him home within four hours of the call. I understand that I may be called at any time of the night or day to arrange for my child's transportation home and that I will be responsible for all costs associated with such transportation.
If my/my child's medical information should change prior to the program, I will notify the Sikh Research Institute of any new conditions, medications, limitations, etc.
I understand that I/my child, alone or with other participants and/or Sikh Research Institute staff, volunteers, or representatives, may be interviewed, may provide written or oral statements, and/or may be photographed, recorded on film, audio tape, videocassette, or other visual and sound, computerized, telephonic, voice-mail, or tape media (photographs and/or sound/image recordings) by the Sikh Research Institute, and/or others approved by the Sikh Research Institute.
I hereby consent to the foregoing and grant permission, without reservation, to the Sikh Research Institute and/or those approved by the Sikh Research Institute to generate, prepare, advertise, describe and/or publicize the Sikh Research Institute's work, good will, public education, and/or fundraising activities, disseminate, otherwise use, and comment upon the photographs and/or sound/image recordings as they may determine, without review by me or my child and without financial or other obligation of any nature to me or my child.
I consent that I or my child may be identified by name, age, and place of residence or otherwise, as the Sikh Research Institute and/or those approved by the Sikh Research Institute may determine.
I consent that I/my child, with other participants and Sikh Research Institute staff, volunteers may take a field trip during the two week program. I understand that I/my child will be transported by public or private vehicles.I also authorize the staff/volunteers to take emergency action(medical attention) should a situation occur requiring such action.
I release Sikh Research Institute, its Board of Directors, employees, agents, and volunteers from all claims that I or my child may have, or might have, for any cause of action arising out of taking and/or use of the photographs and/or sound/image recordings as set forth herein.
This consent and release shall continue in effect, without a limitation of time.
I DO consent or agree to the photo release terms mentioned above. I DO NOT consent or agree to the photo release terms mentioned above.
By stating my name or parent/guardian's name below, I have read and understood all the registration documents required for my/my child's participation in the Sikh Research Institute's program.
Applicant's Name: *
All refund requests must be received within 7 days after the first day of the program not attended; up to 50% of the program fee will be refunded. Refunds will only be considered in the instance of certifiable illness or extenuating emergency circumstances. In the event that a participant must be dismissed from the program for any reason, no refund will be made except for certifiable illness. The application Fee of $100 is non-refundable.
Please submit the application and fee online. You can also send in the Sidak fee (make checks payable to the Sikh Research Institute) to:
Sikh Research Institute | P.O. Box 6317 | Bridgewater, NJ 08807.
If you have any questions, please contact us at: 210.757.4555 or email@example.com.