SPORTS AUTHORITY OF INDIA
LAKSHMIBAI NATIONAL COLLEGE OF PHYSICAL EDUCATION
P.B. No3, Kariavattom, Thiruvananthapuram-695581
Tele:-0471-2418712 Fax-2414771, E_mail: sailncpe@gmail.com
Application Form for Admission under “COME & PLAY SCHEME”
Please attach two passports
Sports Disciplines
Size photographs
1. Athletics 7. Handball
2. Boxing 8. Kabaddi
3. Basketball 9. Swimming
4. Cycling 10. Tennis
5. Cricket 11. Takewondo
6. Gymnastics
……………………………………………………………………………………………………
1. Name :
2. .Address :
3. Telephone No :
4. E-mail address :
5. Date of birth :
6. Age :
7. Educational Qualifications :
8. Name of School/College/ Dept. :
9. Father’s Name & Occupation :
10. Sports discipline/Game applied for :
(Please write the name of Discipline
from list at the top)
11. Category :
(General/Girl/Govt.School Child/
Below Poverty Line (BPL)
-2-
12.Achievements in Sports for last 1 year, if any:
(Documentary proof in support to be attached)
13. Any other information you think relevantfor considering your application:-
…………………………………………………………………………….
14. Mandatory requirements: - Copy of medical fitness certificate in the prescribed form.
I declare that the information given above is correct and undertake to abide
by the rules and regulations laid down/ that may be laid down.
Date:- (Signature of applicant)
…………………………………………………………………………………………………
Signature, Name & Stamp of Head of Institute/
School/ Department or Identity Proof
……………………………………………………………………………………………
Recommendation of Coach
Approved for issue of card/Not Approved
Date: - Signature of Coach
…………………………………………………………………………………………………
(For office use only)
Received a sum of Rs………(Rupees……………………………………………only)
towards registration/membership fee for the quarter ending……………… vide Receipt
No………….dated……… Card No……….. /renewed on………………valid up
to……………………
Officer -In-charge
SAI-LNCPE
(3)
Rules and Regulations
1. SAI will not be responsible for any injury/loss of life during the playing period and no
compensation or claim will be entertained.
2. All instructions imposed by SAI or its authorized representative will be strictly
adhered to.
3. Membership Card will be brought every day and will be shown on demand from
Authorized officer.
4. Pets are not allowed inside the Stadia Complex.
5. Any deliberate damage/loss caused to the stadia property will be recovered from the
member.
6. Stadia Authority reserves the right to suspend/cancel the membership of any
individual without giving any prior notice/ reason in the interest of efficient functioning
of the arrangements.
7. The access to the family members is limited to areas mentioned on the card.
8. SAI will not be responsible for any loss of any valuable/ cash.
9. Fee will be collected a week before the month from members between 2:00pm to
4:00 PM. The card automatically gets cancelled, if not renewed within stipulated
period.
10. No refund or adjustments of fee will be made in case the Swimming Pool & other
facilities are closed for maintenance or for any other unavoidable reasons.
11. Documents required for member ship: Two passport size photographs, residential
Proof or Identity proof, date of Birth Certificate, Medical Fitness Certificate and also
the applicant should not suffer from any contagious disease.
12. SAI reserves the right to change the Training time as and when required.
13. I have read the above rules and regulations and hereby undertake to abide by them.
(Signature of the applicant) (Signature of guardian)
(4)
MEDICAL CERTIFICATE
(To be certified by a Registered Medical Practitioner)
Name:-………………………………………………………Sex:-………………………………
Height:-……………………………………………………..Weight (in Kg)……………………
Physical appearance and Musculature……………………………………………………………
Robust/Average/Weak……………………………………………………………………………
Previous fracture, joint injuries (give details)……………………………………………………
B.P………………………………………………………
C.N.S …………………………………
C.V.S …………………………………
Respiratory System …………………………………………………………………………
Liver …………………………………………………………………………
Spleen …………………………………………………………………………
Hernia sites …………………………………………………………………………
Throat …………………………………………………………………………
EarsPerforation/discharge/anyother mention)………………………Hearing……………………
Eyes……………………………………………Vision with glasses……………..
(Colour Blind Partial/Complete)
Any abnormality, physical defect or disability (such as Kyphosis, Scoliosis, Knock Knees, Flat
Feet, Obesity)…………………………………………………………………………………
History of Epilepsy, Asthma, T.B , Allergy, etc.
Sensitivity to drugs, if any……………………………………………………………………
I certify that I have this day carefully examined (name)…………………………….
And recorded my observations as given above. I am satisfied that she/he is FIT/NOT FIT to
undergo training in sports which will involve strenuous physical activities and
competitive games.
Date………………… Signature………………………………..
Name ………………………………..
Registration No…………………………
Address…………………………………
………………………………………….
Signature of the candidate ………………………………………….
