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EGRA SAMARPAN FOUNDATION

Post De-addiction Care, Mental Health & Lifestyle Development Centre with Councelling
A Rejistation under trusts Act . 1882 Reg. No. IV 190200754/2025
Egra (Near Central Bus Stand) 721429, Purba Medinipur
DECLARATION CUM INDEMNITY BOND
I, ..................................................................S/O. .................................................................., aged.........years,
presently residing at...........................................................................................................................................
do hereby solemnly declare and state as under:
1. I have voluntarily and on my own accord admitted myself to the Post De-addiction Care & Life Style Development Centre with
counselling facilities run by the 'EGRA SAMARPAN FOUNDATION' and I am aware of the same and have granted my
consent/approval in that behalf.
2. I state that I have been informed about the entire procedure in detail & that I also fully understand & am aware of the implications
& consequences thereof,
3. I also confirm that the entire detail of the said treatment and medication have been given in full detail to me & my parents(s)/
and they have fully understood the implications and consequences thereof.
4. I along with my parent(s) guardian(s) are aware of the provisions of various rules, regulations, bylaws and guidelines in respect to
the governing of such procedure as also laws, rules, regulations and guidelines touching, relating to the same including the
Narcotic Drugs and Psychotropic substance Act 1985 and drugs and cosmetics Act, 1940, and the rules regulations and bye-law
framed there under as also all guidelines and notifications pertaining to the same.
5. I declare and confirm that I have taken upon myself the entire responsibility, liability, risk and consequences as may arise during or
after the said procedure and that I shall not in any manner and at any time hereafter hold said post de-addiction care with
counselling centre of the said EGRA SAMARPAN FOUNDATION and the Governing Body as also the Doctors, employees,
staff, counsellor, social workers, representatives liable responsible in any manner whatsoever.
6. I agree and undertake that I shall from time to time hereafter save, harmless indemnify and keep indemnified the said
EGRA SAMARPAN FOUNDATION and the Governing Body as also the doctors, employees, staff, counsellor, social
workers, representatives and all such other person lawfully claiming under them or any them or, their estates and effects against all
suits, action proceedings, claims and demands that may be made taken or adopted against the sold EGRA SAMARPAN
FOUNDATION and the Governing Body as also the Doctors, employees, staff counsellor, social workers, representatives and
other claiming under the them by virtue of them having commenced, carried out and therapeutic process given to me and also from
and against any claim or demand made, taken or adopted by any public body or authority or by any person/persons whom so ever
for any set, deed, matter or thing done, committed, omitted, caused, contemplated, purported or sought to be done any by myself or
by any one whomsoever under my instruction, directions during the course of and alter the completion of procedure or otherwise
howsoever and shall also indemnify and keep informed/ indemnified the said EGRA SAMARPAN FOUNDATION and the
Governing Body as also the Doctors, employees, staff, counsellor, social workers, representatives and all persons legally claiming
by and from under or in trust for them and against all costs, charges, expenses, damages, penalties or payment that they or any of
them have to suffer or insure or put to by virtue of them having commenced, carried out, completed/terminated or stopped the said
procedure to me.
7. I future agree and undertake this indemnity shall insure for the benefit of the said EGRA SAMARPAN FOUNDATION and the
Governing Body as also the Doctors, employees, staff, counsellor, social workers, representatives or any of them and all
persons/parties claiming under them or any of them.
8. I am aware of all the statement and declaration made by myself in this declaration-cum-indemnity on the of day of and I hereby
confirm and ratify the same. I further state that I am aware of all the statement, declarations from executed, filled by my
percent(s)/guardian(s) and me and I hereby confirm and ratify the same.
9. I further agree and undertake that the statements, undertaking and indemnities hare in contained shall remain in full force and
affects for all times to come for the benefit of the said EGRA SAMARPAN FOUNDATION and the Governing Body as also the
Doctors, employees, staff, counsellor, social workers, representatives and such other persons claiming under them or any of them
for all times here after.
10. I am making this declaration solemnly and sincerely without any force, coercion of under influence and the full force and effect
should be given to all statements and declarations made me here in above.
Solemnly declaration at EGRA SAMARPAN FOUNDATION on this....................day of.....................of .............. by the within named.

.................................................. ......................................................................................
NAME IN BLOCK (SIGNATURE OF THE PERSON ADMITTED)
In the present of

.................................................. ......................................................................................
NAME IN BLOCK (SIGNATURE OF GURDIAN)
In the present of