Medical Form

MEDICAL FITNESS CERTIFICATE
(To be filled in by a registered medical practitioner in BLOCK LETTERS)

I certify that I have on this (date)…………….day of(month) ………………, 200….,
medically examined the following person:

Name: …………………….…….………………………………………………..
Son/Daughter/Wife* of ……………………………………………
and/or student of (institution name)……………………………………………….
Age: ………………………., Weight: …………………………………………
Pulse rate: ………………. Blood Pressure:………………………………….
Blood Test:……………….. Blood Group: ………………………………….
Applicant should not have Asthma, Epilepsy or other fits, and any major deformity, hernia & chronic diseases.

In my opinion, Mr/Miss/Mrs…………………………………………………………………. Whose’s signature is given below is fit to undergo ……………………………………..……. (name
of the camp/trek/tour/safari) being organized by Travel With Meera,
Manali, Himachal Pradesh, during the period (dates, from/to) ……………………………….

Participant’s Signature: ………………………………………………………………………………………

Address: ……………………………………………………………………………………………

……………………………………….……………………………………………………..

Medical Practitioner’s name in BLOCK LETTERS: ……………………………………..
Professional seal:

Medical Practitioner’s signature: …….……………………………………………………. Address: ………………………………..…………………………………………………………..
…………………….………………………………………………………………………………….
Date : Place:

Note:
The medical practitioner should be M.B.B.S. and give his/her registration No. of medical council.
All disputes subject to jurisdiction within Manali only.

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