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Fityan Assyakirin Youth Unit Ar-Rijal Cup 2013 Indemnity Form

Participants Particulars (please fill up in BLOCK letters)


Name NRIC No.

Address

____________________________________________________ _____________________________ ____________________________________________________


Contact No : Postal Code : ________________

(H) : ________________________
(HP) : _________________________

Allergy/Medical History :
(please

specify)

Age : Email :

DOB (dd/mm/yyyy)

Gender : Male / Female

Race :

Parents / Guardian Contact Number : Hp:

(Father/Mother)

Declaration & Indemnity (Must Be Completed By Parents / Guardians Of Participants below age 21 years old ) I, ______________________________________________________ of NRIC No. _________________ , *Parent / guardian of ________________________________________________ , *do/do not consent my *child/ward to participate Ar-Rijal Cup 2013. I have understood the risk involved in the event and acknowledge that the Ar-Rijal 2013 Committee has taken every precautionary measure to ensure my childs safety. I also understand and noted that the Ar-Rijal Cup 2013 Committee will not hold any responsibility for any injury or mishap that might occur on my *child/ward throughout the programme. I also understand that I am financially responsible for any medical treatment and/or emergency evacuation resulting from participation in any activities. In the event my *child/ward is not able to attend the programme indicated above, I understand that any fees paid will not be refunded. I hereby certify that the above information given to the organizer is certified true and correct at the time of submission. ________________________________ PARENTS/GUARDIAN SIGNATURE ____________________ DATE

Fityan Assyakirin Youth Unit Ar-Rijal Cup 2013 Indemnity Form

Declaration & Indemnity (Must Be Completed By Participants 21 years old and above) I, ________________________________________________of NRIC No. _____________________________, hereby participate the Ar-Rijal Cup 2013 on Saturday, 14 December 2013, understood the risk involved in participating in the event and that the organiser has taken every precautionary measure to ensure my safety. I do hereby declare that I waive and release Ar-Rijal 2013 Committee and all who may concern from any loss and/or damage from of property, loss and/ or injury to my life. I also understand that I am financially responsible for any medical treatment and/or emergency evacuation resulting from participation in any activities. In the event I am not able to attend the programme indicated above, I understand that any fees paid will not be refunded. I hereby certify that the above information give to the organizer are certified true and correct at the time of submission.

________________________________ PARTICIPANT SIGNATURE

____________________ DATE