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Saeyls 2012 Registration Form

Saeyls 2012 Registration Form

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Published by Elsa Asri

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Published by: Elsa Asri on Jan 08, 2012
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01/08/2012

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Jalan 14/49, 46100 Petaling Jaya, Selangor, Malaysia Phone: 603-78765041 Fax: 603-78775658 Website: http://www

.saeyls.blogspot.com Email: saeyls@hotmail.com
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.

Sri Aman Girls’ School

REGISTRATION FORM FOR STUDENTS

PICTURE OF PARTICIPANT

Name of the participant: _______________________________

School:____________________

Country:________________

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PARTICIPANTS PERSONAL INFORMATION
Full Name in Block (as in Passport)

Sex

Blood Group

Height (in Cm)

Weight (in Kg)

T-Shirt Size (S/M/L/XL)

Date of Birth (DD/MM/YYYY)

Age on 01/11/2011

Home Address

Email

Home Phone

Mobile Phone

Country of Birth

Nationality

Passport Number

Passport Expiry Date

Passport issuing Country

Special Dietary Requirement (e.g. Vegetarian / Non-Vegetarian / any food allergy )

PARENT’S/ GUARDIAN’S PERSONAL INFORMATION
Full Name in Block (as in Passport)

Email Id

Office Telephone Number

Mobile Telephone Number

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EMERGENCY CONTACT’S PERSONAL INFORMATION
Full Name in Block (as in Passport)

Home Number

Office Number

Mobile Number

SCHOOL DETAILS & INFORMATION
Name of School

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: Participant’s Class/Year/ Level as of January 2012 Grade 9 / 10 / 11 / 12

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PERSONAL HEALTH PROFILE
My general state of health is: My level of fitness is: Good High Fair Medium Poor Low

Are you currently taking medication? Yes / No If yes, please specify:

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:

PARTICIPANT ACKNOWLEDGEMENT FORM
(TO BE COMPLETED AND SIGNED BY PARTICIPANT)

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.

___________________ Signature of Participant

_________ Date

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PARENTAL CONSENT FORM
(TO BE COMPLETED AND SIGNED BY PARENT/ GUARDIAN OF PARTICIPANT)

I, _______________________________[name in full], parent/ guardian of child/ward, _________________________________[child’s/ward’s 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 child’s / ward’s 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.

________________________ Signature of Parent/ Guardian

_______ Date

VERIFICATION BY SCHOOL
It is to certify that the information provided above by the student is true as per our school record.

______________________ Signature of Headmistress

________________________ Name of the School with Seal

_______ Date

For further queries, please contact us at saeyls@hotmail.com

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