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Please email us the softcopy of the Filled Registration Form with all the signatures and seals along with an attached digital passport sized photograph of high resolution good enough for printing purpose.
PICTURE OF PARTICIPANT
School:____________________
Country:________________
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Sex
Blood Group
Age on 01/11/2011
Home Address
Home Phone
Mobile Phone
Country of Birth
Nationality
Passport Number
Email Id
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Home Number
Office Number
Mobile Number
Name of the Principal/Head of the School with Email-id NAME OF PRINCIPAL: EMAIL ADDRESS: School Address with Phone & Fax Number ADDRESS: PHONE NUMBER: FAX NUMBER: School Website & Email Addresses SCHOOL WEBSITE: EMAIL ADDRESS: Participants Class/Year/ Level as of January 2012 Grade 9 / 10 / 11 / 12
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Have you been hospitalized in the past 12 months? Yes / No If yes, please provide details: Do you have any allergy or allergy to any medicine? Yes / No If yes, please specify:
I, ___________________________________ [participant name in full], hereby declare that the information given is true and comprehensive. I fully understand that the activities carried out by The SAEYLS Organising Committee may be mildly to moderately physically demanding. I will not hold The SAEYLS Organising Committee responsible for any loss of personal property or any injuries sustained during the course of the programme. I will ensure that I understand and adhere to all activity instructions and accept any associated risks involved.
_________ Date
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I, _______________________________[name in full], parent/ guardian of child/ward, _________________________________[childs/wards name in full] hereby give permission for him/her to attend the Sri Aman Environmental Youth Leadership Summit 2012 (SAEYLS 2012) that will be held from the 10 th to 18th March 2012 in University Malaya, Petaling Jaya, Selangor, Malaysia. I also understand that some of the activities in this convention may be physical in nature and be held outdoors. I also understand that my childs / wards comfort and safety may be dependent on his/her bringing the stipulated equipment and his/her exercising good judgment whilst participating in all activities. I hereby declare that all the medical information provided above is accurate. I authorise The SAEYLS Organising Committee to obtain medical assistance when they deem necessary in the event of any illness or accident suffered by my child / ward. I agree to pay for any medical and emergency transport services incurred on his/her behalf. I hereby declare that I will not hold The SAEYLS Organising Committee responsible for any damage to or loss of personal property or any injuries sustained by my child/ward during the course of the programme. I certify that the information provided on this form is true and comprehensive.
_______ Date
VERIFICATION BY SCHOOL
It is to certify that the information provided above by the student is true as per our school record.
_______ Date
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