Jagriti Yatra 2013 We welcome your decision to participate in Jagriti Yatra 2013. To participate in this Yatra you need to fill up this Application form. Your form will go through a stringent, pre-designed Selection process before the final selection. To improve your chances of selection, answer all the questions carefully and in detail. Submit your application well in advance of the last date to improve your chances of selection For submitting your application you have two options. You may post the hand-written form or type in MS Word and e-mail it to us. Please Note: The aim of this application is to judge your ability to become a genuine change - maker. Please fill in the application form honestly and respecting the spirit of the Yatra. 1. Incomplete applications will be rejected. 2. One candidate can submit only one form. If two applications are submitted both will be rejected. 3. Do not exceed the word limit. 4. Do not cut-paste from the internet or borrow ideas from others. We want your original thoughts. 5. Random checks are carried out to confirm the veracity of your application. Dishonest applications will result in debarring the candidate. Address E-mail selection@jagritiyatra.com Jagriti Sewa Sansthan (Please mention registration form in subject) B 5,Green Acres Housing Society, Off Din Quarry Road, Panjarpole, Contact No. 022 64535354 / 022 25550936 Deonar, Mumbai 400 088 Jagriti Sewa Sansthan Page 1 of 10
Application Form Jagriti Yatra 2013 Registration Name: (First Name) (Last Name) Contact no. : Alternate Contact no. : E-mail address ( if any) : How did you first find out about the Yatra? (Newspaper Article, Newspaper Ad, TV Ad, Radio Ad, Website, SMS, Company announcement, School/College poster, E Sahaj, Blog, From a friend, JY awareness ambassador) You wish to apply in Hindi English Jagriti Sewa Sansthan Page 2 of 10
Application Form Complete permanent postal address: (with City, District, State and pin code) Permanent Country : Permanent State: Permanent District : Permanent City/Town: Complete current postal address: (with City, District, State and pin code) Current Country : Current State : Current District : Current City : Parents/Guardians email : Please specify what kind of place you have spent maximum years in: (Rural/urban/semiurban): Age : Gender : Level of education: (high school/graduate/post-graduate) Qualification and specialization: Occupation: (student/student and working/ working) Jagriti Sewa Sansthan Page 3 of 10
If you were to start an enterprise which sector would it be: (Agriculture and Farming enterprise, Energy and Climate enterprise, Water and Sanitation enterprise, Education and the Knowledge enterprise, Communications technology enterprise, Manufacturing enterprise, Health enterprise,arts) Institute studying in: Organization/ Company you work for : Applied for previous yatra: ( 1997/2008/2009/2010/2011/2012 none) Status : (selected/rejected/selected but could not participate) Would you be a self-paid Yatri or require sponsorship?: (require sponsorship / part paid/ self paid) (Please note that sponsorships are extremely limited and awarded to the most deserving candidates only. All candidates opting for sponsorship will have to produce relevant proof of income) The registration and yatra fee details are as follows: 1) Self Paid Yatri: (I agree to pay registration fees of Rs 4500/- and Yatra fees of Rs. 42,000/- International Participants agree to pay 1200 USD or 720 GBP) 2) Part sponsored Yatri:( I agree to pay registration fees of Rs 4,500/- and part Yatra fees of 21,000/-. I request sponsorship for the balance Yatra fees of Rs. 21,000/-) 3) Fully sponsored Yatri(I agree to pay registration fees of Rs 4,500 I am unable to pay the Yatra fees and request full sponsorship of Rs 42,000/-) Are you applying as a Participant or Facilitator? : (Participant / Facilitator) Facilitator option available only if age above 25 : A Participant is a normal Yatri, however enthusiastic and energetic candidates above 25 years of age are urged to take the role of Facilitators. The role of Facilitator is twofold- that of a coordinator and a mentor. The Facilitator is expected to manage his/her group throughout the journey and help them form a cohesive group of learning. He/she will initiate discussions, share knowledge and guide interactions between diverse Yatris. Your profile ( which includes education background, field of interest and work done if any) (50 words) Jagriti Sewa Sansthan Page 4 of 10
QUESTIONS 1. Do you have role model/models in your life? (Mention not more than2) Why do you admire her/him/them? (200 words) 2. What is the biggest challenge you have faced to date? How did you deal with it and what did you learn from it? (200 words) 3. Would you like to be a social/ business entrepreneur? Why? (100 words) 4. Have you already done something which demonstrates social or business entrepreneurship? Describe this venture. (This could be a school or college project or venture or a hobby you converted into a business, or something beneficial for your local community.) (200 words) 5. Which do you think is the single biggest challenge India/your community (choose any one) will face in the next decade? How would you address this challenge? (200 words) 6. If there is any other relevant information you wish to add in terms of your creative skills/awards/achievements, please do so here (100 words) 7. Why do you want to come on the Yatra? Why should you be selected for Yatra 2013? (200 words) REFERENCES This should be a mentor/ teacher/ employer/ business associate who has known you over a significant period and can vouch for your credentials and character. Name of Reference How does the reference know you? Jagriti Sewa Sansthan Page 5 of 10
Contact details If you want to participate as a FACILITATOR please fill this section 1. Why do you want to be a Facilitator on the yatra? (200 words) 2. Write briefly about your professional experience highlighting your work in youth related programs, social enterprise and any other aspects you feel relevant to the yatra (200 words) 3. What specific value do you think you will add to the yatra as a Facilitator? (200 words) Jagriti Sewa Sansthan Page 6 of 10
SPONSORSHIP FORM Are you earning : Yes/No State the no. of family members : Your families annual income is : ( Less than Rs.3,00,000 / Between Rs 3,00,000 and Rs 7,00,000 / Between Rs 7,00,000 and Rs12,00,000, Above Rs 12,00,000 ) ( A copy of any authentic document supporting the income mentioned MUST be attached with form) Give your family background: ( 200 words) Why do you think you deserve sponsorship? ( 200 words) ADDITIONAL PERSONAL DETAILS Mother tongue: Fluent in hindi, english : hindi/ english / both : Hobbies photography/video shooting/ dramatics/writing/reading/other Blood group : a rh +ive, a rh ive, b rh +ive, b rh ive, o rh +ive, o rh ive, ab rh +ive, ab rh ive Prolonged Ailment ( if any ) : check box Nil Jagriti Sewa Sansthan Page 7 of 10
Migraine Epilepsy/convulsions Psychiatric disorders Asthama Thyriod disorders Heart problems Ulcers, Piles Kidney problems Blood disorders Gynaecological problems Hypertension Diabetes Liver disorders Skin disorders Give details of the ailment you mentioned: ( this will appear only if an option other than nil is selected) Mention significant allergies: yes/no Give details here : Details of Medical History: Health Precautions and Dietary Restrictions: TERMS OF REGISTRATION Jagriti Sewa Sansthan Page 8 of 10
1. Jagriti Yatra is a project of the Jagriti Sewa Sansthan, which aims to promote enterprise led development across India through a national train journey. This journey is organized on a charitable basis, and we expect selected participants to abide by the rules set out for participants for the Yatra (which will be sent in the welcome pack), as well as the following terms of registration for the selection and payment process. 2. Jagriti Sewa Sansthan and its project Jagriti Yatra unilaterally reserves all rights to add or modify or cancel any Terms and Conditions of the Yatra at any time without any notice, with or without assigning any reason for the same. 3. This includes rejection of any candidate at any stage of the selection process of the Jagriti Yatra. 4. Jagriti Yatra reserves all rights to seek the evidential support documents to authenticate the information declared or claimed by the applicant in the applications submitted, including age, address, phone, education, financial details etc. 5. Jagriti Yatra at its discretion may also seek the applicant to comply with certain requirements. These include appearing for an interview to know more about the applicant, giving an undertaking to the Jagriti Yatra to cooperate with the program of the Yatra, with proper conduct and behavior all through the journey. 6. With respect to the selection of a candidate the decision of the selection committee will be final and details of scores/viewing of application forms/or similar information will be not be entertained. 7. Whilst this is our endeavor to keep you posted of the developments, we make no representations/warranties/commitment/undertaking of any kind, expressed or implied, about the commitment, completeness, accuracy, reliability, suitability or availability with respect to the Yatra. Any reliance you place on such information/intimation is therefore strictly at your own risk. In particular please keep in mind that the train schedule is approximate and subject to change 8. In no event will we be liable for any loss or damage, indirect or consequential, arising from injury or death during the event. Yatris are advised to take out their own insurance policies for the duration of the journey. 9. We are also not liable to loss of profits arising out of, or in connection with, the use of information/intimation from us/ our website. 10. You are not allowed to join or leave the Yatra midway 11. If for any personal reason you are to leave the Yatra mid-way you would have deprived another potential candidate the opportunity to travel on the journey and therefore you, will have to pay Rs 42,000/-. This amount may be moderated in exceptional personal circumstances by written agreement from the organizing team. Also please note that in such case you will not be issued a Certificate of Participation in the yatra. Jagriti Sewa Sansthan Page 9 of 10
12. The organizing team of Jagriti Yatra reserves the right to de-train any candidate during the journey for misconduct or misbehavior. This will be at the sole discretion of the organizing team, and any fees deposited will not be refunded. Refund Policy 1. Registration and membership fees of Rs 4,500 will not be refunded in any case 2. Yatra fees will be refunded only if cancellations in writing, through email or post, are informed before 30th November 2013. 3. If a self paid / part paid candidate, for any reason is unable to attend the Yatra, only the Yatra fees Rs. 42,000 or Rs. 21,000, whichever applicable, will be refunded 4. Refunds will have to be claimed before the 31 st of Jan 2014. Refunds claimed after this will not be entertained. 5. An amount of Rs 2000/- will be deducted from the Yatra fees as Refund processing fees. 6. If eligible for refund, the Yatra fees will be refunded within three months of commencement of the Yatra. I have read the rules, regulations and refund policy and agree with the terms described. Please choose this option carefully since if you select the option No your selection (if selected) stands cancelled. Yes/No Sign: Date: Jagriti Sewa Sansthan Page 10 of 10