PARTICIPANT’S DETAILS

GLOBAL YOUTH SYMPOSIUM 2008

UNIVERSITY OF MALAYA, KUALA LUMPUR
19th – 23rd AUGUST 2008

NAME OF UNIVERSITY/ COLLEGE : ________________________________

COUNTRY : _____________________________________________________________

PERSONAL DETAILS

GIVEN NAME : ________________________________________________

SURNAME : ________________________________________________

AGE : ________________________________________________

GENDER : MALE / FEMALE

COURSE : ________________________________________________

YEAR OF STUDY : ________________________________________________

DATE OF BIRTH : ________________________________________________

PLACE OF BIRTH : ________________________________________________

ADDRESS : ________________________________________________

E-MAIL ADDRESS : ________________________________________________

CONTACT NUMBER : ________________________________________________

GENERAL INFORMATION
(Please circle one)

1. Are you a vegetarian ? YES / NO

2. If yes, would you eat egg/fish during this symposium ? YES / NO

3. Do you have allergies, asthma, dietry restrictions or medical

problems ? YES / NO
If yes, please describe.

__________________________________________________

I, ………………………………… from ……………………………. agrees :

(participant’s name) (university’s name)

(i) that once confirmation has been made, I will NOT WITHDRAW from
this symposium AFTER JUNE 20TH 2008. If any unforseen
circumstances were to occur, ………………………. ……………………..
(Participant’s University Name)
will arrange for a substitute

(ii) that if the organiser had taken all NECESSARY PRECAUTIONS, it

will NOT BE HELD RESPONSIBLE for any injuries, accidents or
death that may occur to me during the symposium.

Yours sincerely, Approved by,

______________________ ___________________
Participant’s Signature Name :
Date: Position :
Date :

______________________
University Stamp
Date