SIDAK

Registration Form 

Instructions: Please read carefully, fill in the information, and sign. If the applicant is under 18 years of age, both the
applicant and their parent/guardian must sign. The application will not be processed if required signatures are missing.

PERSONAL INFORMATION

NAME First Middle Last

ADDRESS No. & Street City State Zip

PHONE Home Cell Work

Email

D.O.B. MM/DD/YR

EDUCATION School/College Grade/Year Major/Minor

FATHER Name Job Title Employer

Email Phone

MOTHER Name Job Title Employer

Email Phone

ADDRESS (if different from applicant’s) No. & Street City State Zip

PROGRAM REQUESTED

Program Applied For: Sikhī 101 Sikhī 102 Gurmukhī 101

Have you attended Sidak before? No Yes

If yes, in which program did you participate? Sikhī 101 Sikhī 102 Gurmukhī 101

PAÑJĀBĪ/GURMUKHĪ KNOWLEDGE

Gurmukhī Script skills (check one):

None Extremely Limited Read & Write Fluent

Pañjābī Language skills (check one):

None Extremely Limited Understand & Speak Fluent

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ADDITIONAL INFORMATION

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.

1. How did you hear about Sidak?

2. Please tell us about your past and present involvement with the Sikh community and Sikhi-related
activities.

3. Why do you want to attend Sidak?

4. In what areas of Sikhi do you feel you most need to grow and learn? What are your
expectations of the program?

5. How would you like to apply what you learned at Sidak when you return to your home and/or
college communities?

Any other considerations you would like to bring to the organizer’s attention.

MEDICAL INFORMATION

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 the Institute prior to the applicant’s involvement in the
program. Please make sure to provide detailed and accurate information so the Institute is aware of your (child’s) needs.

List any dietary restrictions below.

EMERGENCY CONTACTS

1. Name Relationship Phone

2. Name Relationship Phone

Do you have any physical limitation that might restrict participation in program activities? No Yes
If yes, please explain.

Have you required medical treatment for an injury within the last year? No Yes
If yes, please explain.

Have you received any treatment for any medical or psychological condition within the last year? No Yes
If yes, please explain.

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Is there any medication you currently take regularly?

ALLERGIES

Allergies to Medication
List all known
Describe allergic reaction and its medical solution

Allergies to Food
List all known
Describe allergic reaction and its medical solution

Other Allergies
List all known
Describe allergic reaction and its medical solution

MEDICATION

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.

Do you take medication on a routine basis? No Yes

Will you be taking any prescribed medication during the program? No Yes

If yes, please provide the following information (attach additional pages for more medications)
Medicine Dosage Specific times taken each day
Reason for taking

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 the Institute should be aware of? (Please elaborate)

INSURANCE INFORMATION

Is the applicant covered by family medical/hospital insurance? No Yes

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

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

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attention as may be deemed necessary for the health and safety of me/my child. In the event that I 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.

APPLICATION AGREEMENT

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 picking me up 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 the 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 Institute and/or its Board of Directors, employees,
volunteers, or lessors including those claims that may arise from negligence of the Institute, and/or its Board of Directors,
employees, volunteers, or lessors.

If the Institute must send me/my child home for any reason, I agree to pick her/him up 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 Institute of any new
conditions, medications, limitations, etc.

I understand that I/my child, alone or with other participants and/or 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 Institute, and/or others approved by the Institute.

I hereby consent to the foregoing and grant permission, without reservation, to the Institute and/or those approved by the
Institute to generate, prepare, advertise, describe and/or publicize the Institute its work, good will, public education,
and/or fundraising activities, disseminate, otherwise use, and comment upon the photographs and/or sound/image

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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 my child may be identified by name, age, and place of residence or otherwise, as the Institute and/or those
approved by the Institute may determine.
I release the 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.

SIGNATURES

I have read and understood all the registration documents required for my/my child’s participation in the Sikh Research
Institute’s program.
Applicant Name (Print)

Applicant Signature ____________________________________ Date

Parent/Guardian Name (Print)

Parent/Guardian Signature ____________________________________ Date

Enclosed with the completed application is:

Full Payment in the Amount of $500
Registration Fee of $250 (whereupon the remainder $250 will be due upon arrival)
Waiver consideration: If you wish to apply for waiver consideration, please answer the following questions:

1. Amount of Registration Fee applicant is able to pay: $

2. Estimated cost of travel (please include flight expenses, cost of visa, etc.): $
3. Are you a: High School Student College Student Employed
4. Martial Status: Single Married Divorced/Separated Number of Dependents
5. Please explain any unusual expenses, other debts, or special circumstances that the Institute should consider
when deciding how much to sponsor your participation. Use additional paper if necessary.

Applications for waiver consideration will be accepted up until the application deadline. Completed applications will be
considered on a first come, first serve basis while funding is available. Applicants will be notified 15 days after the
receipt of their application.

REFUND POLICY
All refund requests must be received within 10 days after the first day of the program not attended; up to 50% of the
registration fee will be refunded. In the event that a participant must be dismissed from the program for any reason, no
refund will be made except for certifiable illness.

Please send the signed registration form with fee (make checks payable to the Sikh Research Institute) to:
Sikh Research Institute | P.O. Box 690504 | San Antonio, TX 78269-0504.

If you have any questions, please contact us at: 210.582.3371 or info@sikhri.org.

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 OFFICE USE ONLY
Application Approved Denied Reason for Denial
Reviewed By Date
Acceptance Notified No Yes Date
Sponsorship Approved Full Partial Other

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