Medical Camp Registration Form

Step 1 of 4

Medical Camp Registration Form

Bidada International Foundation
11403 Tortuga St
Cypress, CA 90630 USA

In consideration for Bidada International Foundation (the “Foundation”) admitting me as a volunteer for the Medical Camp (the "Program"), which may involve travel to, from, and within the country India.

I hereby:

(a) release and discharge the Foundation from any liability or responsibility for any injury (including death), and for any damage to or loss of property, howsoever caused, that I suffer as a result of or in connection with my participation in the Program or any travel related to the Program, including, without limitation, any injury, loss, or damage resulting from, arising out of, or occurring in connection with the negligent acts or omissions of members of the Foundation or other employees or agents of the Foundation; and

(b) agree not to raise any claim or to institute any legal action or proceeding against the Foundation for any cause of action that may result from or arise out of or in connection with my participation in the Program or any travel related to the Program, including without being limited to, any cause of action that may result from or arise out of or in connection with the negligent acts or omissions of members of the Foundation or other employees or agents of the Foundation.

All references to the Foundation in this form shall include, and all provisions of this form shall inure to the benefit of, the Foundation members, officers, employees, agents, servants and representatives.

I will inform an appropriate representative of the Foundation named above of any special information regarding my health, physical or mental condition, that may be relevant to my participation in the Program or any travel related to the program.
Name*
First Last
Date*
MM slash DD slash YYYY
Date of Birth (DD/MM/YYYY)*
DD slash MM slash YYYY
Disclaimer*
- By checking this box I agree to the terms and conditions stated above.

Bidada International Foundation
Medical Camp Registration Form
Name:*
First Last
Gender:*
Age:*
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:*
Secondary Phone:
Address in India:*
Is Your Address Same as Above?
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Participant Status:*
If Resident, Year:*
If Med Student, Year:*
If Physician/Resident/Medical Student/Nurse:
Medical Degree:
Institution:
Year Issued:
Professional Affiliation:
If Volunteer:
Education:
Area of Interest :
List two persons in India or abroad that we may contact in the case of an emergency:
1. Name:*
First Last
Relationship:*
Address:*
Is the Address Same as Above?
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:*
Email:
2. Name:*
First Last
Relationship:*
Address:*
Is the Address Same as Above?
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:*
Email:
List any medical conditions we should be aware of, medications used to treat those conditions, and any medications that may induce an allergic reaction:
Additional Information:
Date*
MM slash DD slash YYYY
Disclaimer*
- By checking this box I agree to the terms and conditions stated above.

Bidada International Foundation
Medical Camp Registration Form

Village : Bidada, Taluka : Mandvi, Kutch, Gujarat, INDIA - 370 435
FCRA 1976 No. 042050010

Foreign visitor information required by the Government of India
Are you a Foreign Visitor?*
Serial Number:*
Name:*
First Last
Permanent Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Number:*
Address in India*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Number:*
Nationality:*
If Other, Please specify:*
Purpose of Visit:*
If Other, Please specify:*
Amount of Donation in Indian Rs. (If Any):
Details of Last visit (If Any):
Duration of this Visit From (Date) - To (Date)*
Details of the Place of stay in India (Specially Night Stay):*
Kindly Provide Alt. Address:*
Link between foreigner and NGO / Trustees:*
If Other:*
Mode of Conveyance adopted by the foreigner:*
Visiting from, Arriving to (Specify City, State, Country*
Passport Number with Date of Issue:*
VISA Number:*
Type of VISA (Business, Tourist etc.):*
Validity of VISA (From - To):
All information must be filled out by participants in order to process registration.

In order to attend the medical camp, travel and lodging arrangements from Mumbai to Bidada and back to Mumbai must be made well in advance. To avoid any last minute difficulties the Foundation makes all the necessary reservations and arrangements for its attendees. Please take note of the available travel options with pricing listed below and select the one that best fits your needs. Prices are listed by form of transportation and duration of stay; a donation to the Foundation is suggested but not required.
Travel Options
Mode of Transport:*
Duration of Stay:*
Duration of Stay:*
Donation (Optional)
Total
$0.00
Payment for these accommodations can be submitted to the Foundation online via PayPal, or by mailing a check to the address below. Funds collected are not refundable but are tax deductible.

Bidada International Foundation
11403 Tortuga St
Cypress, CA 90630 USA

To ensure that the necessary arrangements are taken care of in time the Foundation must receive this form as well as payment for the totaled amount as soon as possible. Participants who do not submit payment by this date will not be assisted with travel accommodations between Bidada and Mumbai.

Medical Camp Registration Form

Step 1 of 4

Medical Camp Registration Form

Travel Options

Bank Draft

Provisional degree or diploma or certificate

Certificate of Registration

Certificate from the sponsoring authority

Admission letter from the college / hospital where the training is to be scheduled

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