CILI PADE SWIMMING TEAM

ENTRY FORM

30th National Inter-Club Swimming Championships 2011 for the President Cup, 19th - 21st November 2011, Pusat Akuatik Darul Ehsan Shah Alam, Selangor D.E.
SWIMMER PARTICULARS No NAME
MALE / FEMALE

FREESTYLE Date of Birth & IC No. (Compulsory) Group 50m 100m 50m

BUTTERFLY 100m 50m

BACKSTROKE 100m

BREASTSTROKE 50m 100m

No. of Events

SITI NOOR SYAHIIRAH

2

23/2/2002 IC/BC: 020223-10-0526

IV

50.13

1:47.89

1:04.07

2:34.58

51.70

1:59.68

56.66

2:10.75

Total No. Events

1 Total no. events______8_______@RM 3.00 per event 2 Kit for 2011/2012 season consist of (3 T-Shirts,1 Cap & 2 Shorts) ______1_____ sets @ RM 90.00 per set (Compulsory)

RM24.00 RM90

I, Mohd Elias Bin Ismail I/C No. 670609-07-5575 hereby, give consent to my child/children (name(s) listed above ) to participate in the President Cup 2011 scheduled to be held at Pusat Akuatik Darul Ehsan, Shah Alam, Selangor Darul Ehsan. I will not hold PRAS or the organizers responsible for any accident or injury caused before, during and after the above event.
Notes:1 Provide the best time for every participating event otherwise state NT 2 3 4 5 No amendment is allowed after submission of this Form Closing Date for submission of entry is 18th October 2011 Fee shall be payable upon submission of entry forms Age Groupings are as follows:Group IV - 10 years and below Group III - 11 & 12 years Group II - 13 & 14 years Group I - 15 &17 years Open - 18 to 30 years Date of reckoning shall be 1st January 2011

Total Fees

RM114.00

Signed:

NAME IN BLOCK LETTERS (Parent/Legal Guardian)

MOHD ELIAS BIN ISMAIL

Email Contact No:

(Compulsory)

mohdelias.ismail@my.tesco.com 012-6927423 / 012-6946739

For further information, please contact: Mark Chua (012) 295 2513 Joanne Lim (013) 380 7036

markchua77@gmail.com doouyuan@gmail.com