Name: Mr./Miss. Date of birth: Father s Name: Mother s Name: Educational Qualification:
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3 Annex-I REPUBLIC DAY PARADE CAMP NOMINATION FORM FOR STATE/UT LEVEL SELECTION CAMP A: PERSONAL DETAILS (in capital letters) (i) Name: Mr./Miss (ii) (Surname ) Nomination is for.. (First name) (iii) (iv) (v) (vi) Date of birth: Father s Name: Mother s Name: Educational Qualification: B: CONTACT DETAILS (i) Contact Address & Telephone no. of NSS Volunteer ( College) (ii) Permanent Address & Telephone no of NSS Volunteer ( Residence) C: NSS UNIT DETAILS (i) Name & Address of NSS Prog. Officer (college) E mail ID (i) Name & Address of NSS Prog. Coordinator (University) D: OTHER DETAILS (i) Height (in cm) (ii) Weight (Kg.) (iii) Food habit: Veg/ Non-Veg (iv) Blood Group: (v) NSS Camps attended: (vi) NSS Enrollment Year: (viii) Hobbies: Signature of the Volunteer & Date Signature of the Prog. Officer & Date (SEAL)
4 Annex.-III Certificate of Medical/Physical Fitness A Specimen Signature of the Candidate... I do hereby certify that I have examined Mr./Ms Son/Daughter of.. and found fit for undergoing rigorous training for Pre-Republic Day/Republic Day Camp. The candidate whose signatures are given above is not suffering any communicable or chronic disease, which may cause any hindrance in his/her participation in the above-mentioned rigorous training programme. Station: Signature of the Medical Officer with Seal Dated:
5 Annex.-IV Form of Indemnity A Specimen In consideration of my being nominated at my request to undergo all types of training and also participating in any camp/course/adventure training activities in/outside NSS and traveling I undertake and agree that neither I nor my executer/ administrator will make any claim against the Government of India or against any officer of NSS/Principal/Programme Officer/ Programme Coordinator/State Liaison Officer/Youth Officer/ Assistant Programme Adviser/Deputy Programme Adviser/ Programme Adviser in respect of any loss or injury to the property or person (including injury resulting in death), which may suffer while or inconsequence of my being in training/ participating in any camp/course/adventure training activities in/ outside NSS and traveling and I understand that no compensation will be paid by Government of India or any Officer as mentioned against any such loss or injury (including injury resulting in death) and I agree so as to bind myself, executers and administrators to indemnity to the Government of India, any NSS official and any person in the service of Government of India, against any claim which may be made any third party against them or any of them arising out of any ac or default on my part during or in connection of said training camp/course/nss Pre-RD Parade/RD Parade Camp/adventure training and journey by road/rail/sea/river/flight. Signatures of the applicant with address In the presence of Witness 1 Witness 2 NB: One of the witnesses must be the parent/guardian of the NSS volunteer with address
6 Annex.-V Volunteer ship Certificate A Specimen It is certified that Shri./Kum. Son/Daughter of Shri. is a bona-fide student of (name of institution) He/ She is a regular NSS volunteer from. and has completed his/her one year of volunteer ship and he/she is neither a member of NCC nor a member of Scouts and Guides/ Rovers/Rangers. He has attended NSS Special camp from.to (Date) at (Venue) Signatures of the Programme Officer with seal Signatures of the Principal with seal
7 Annexure VI ARTICLES OF DAILY USE 1. Light bedding 2. Torch with cells 3. White Pullover ( Sweater V Neck) 4. White trousers and shirt ( both for boys and girls) -2 pairs 5. White warm up canvas shoes( 1 pair) 6. White Socks ( 3 pairs) 7. Black shoes ( 1 Pair) 8. Clothes for daily use 9. Dining Plate & Tumbler 10. Daily routine toilet items and medicines of daily use 11. Pair of slippers 12. Warm clothing 13. Baggage which can be locked properly 14. NSS Badge 15. College/ School/ University Identity card 16. Costumes and Musical instruments, CDs, DVDs, cassettes for cultural activities 17. Shoe polish & brush 18. Make up material for cultural activities 19. Activity photographs, banners, posters/cds/dvds, clippings documentaries, report for exhibition 20. Articles for Newsletter 21. Passport size photograph 3 no 22. Participants are advised not to carry with them gold ornaments and valuable items, heavy amount of cash 23. Indemnity Bond as per Performa 24. Physical/Medical Fitness certificate in Performa 25. NSS Volunteer ship certificate in Performa.
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