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Young India, Arise !

Southern Regional Youth Convention 2013

(Kerala, Karnataka and Andhra Pradesh)

Dates: 29, 30, 31 January 2013 (Tue, Wed, Thu)
Registration Form for Delegates
For youth between 16 and 30 years, girls and boys.
Registration on first-come basis
(To be filled legibly in capital letters)

Affix
1 Photo
here and
staple 2 more
photos to this
form

My name (in English): _________________________________________________________________ Gender: M / F

Age: ________Cell phone number (if any): _________________________Email id:_______________________________
Full residential address: ______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________ PIN ________________________ Ph. no. _______________________________
Name and address of my school/college/place of employment: ________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________ PIN ________________________ Ph. no(s). _____________________________
Course/class I am studying in: _________________________________________________________________________
Further details:
1) My skills and talents: singing / dance (classical or traditional) / oratorical (talk, debate or compeering) / drawing / sports
/ athletics and/or others:

2) My food/dietary restrictions:

3) I do not have/I have chronic health problem, for example: ______________________________________

I have attached a Demand Draft for Rs. 100/-; Number: _______________________________
OR
I have sent a Money Order for Rs. 100/- on ____________________ (date)
OR
I have paid in cash Rs. 100/- on ____________________ (date)
(Note: Demand Draft/Money Order is to be payable to Ramakrishna Mission Vidyalaya; cash payable personally
at the Vidyalayas Youth Convention Office between 9:30 a.m. 12:00 noon, 2:00 p.m. 6:00 p.m. Last date

of receiving fees: 15 December 2012)

I have attached my three stamp-size photographs for affixing on ID-card.

[Note: I understand that wearing ID-card (to be received on registration) with photo will be compulsory during the
convention]

I shall arrive at the Vidyalaya on ________________at___________

My signature :_______________________________
My name

Note:

:_______________________________
(Delegate)
1. After filling up this form, send it with attachments to the Secretary, Ramakrishna Mission Vidyalaya,
Periyanaickenpalayam, Coimbatore 641020 and write Southern Regional Youth Convention 2013 on
top right corner of the envelope.
2. Name & Address should be written on the back of the photos stapled.
3. Xerox copies of this form can be taken and sent.