Registration Form Reg.No.

for Alkahfi Intercultural Festival

1. Personal Information * Please fill in the form in BLOCK LETTERS in English.

Full Name (Exactly the same as your passport)
Name Muh. Rizal

Given name (English) Family Name (English) Middle Name (if any)(English)

Muhammad Rizal Rizal

Nickname (English)(Please specify
Full Name (in Mother language)
the name you would like to be called)

Muhammad Rizal

Age (as of the

Date of Birth 02/11/1999 day of the flight to 18
Indonesia)

Country Indonesia Sex 　　　□M

□Buddhist □Christian (□Roman Catholic □Protestant □Other) 　□Not Applicable

Religion □Hindu □√ Muslim □Others (　　　　　　　　　　　 ）

Mother Tongue
Number Type of Passport
□Private □ Diplomat □Official
Passport** Date of Issue Date of Expiry

Facebook Twitter Instagram Other

Social Media User Rizal avwan al thuqhanMuhammad Rizal muh02rizal avwan al bantani
Name(s)
*on a voluntary basis ※ANSOR might use your postings related to Global Intercultural Youth Exchange through above
mentioned SNS in our reports and website, that will possibly be open to the public. You Must post
and share on your social media every place and destination that will be visited.
Phone Number (WA - 82297992722
Call)
Current Address

Contact Person
in case of
Emergency
*It shall be your parent.
*If you live with him/her,
please leave address
blank.
Profession/Occupation ：
*If you do not have a phone E-mail ： salsabilaavwan02@gmail.com
at your current address,
please write a contact
person and number.
**Passport: If you have a valid passport, please fill in the passport section. If you don't have a passport, please leave the section blank.

2.Health Condition * Please fill in the form in BLOCK LETTERS in English.

□ Good
□Previously diagnosed serious disease:
( :□fully recovered / □under
treatment)

Health Condition □Having Chronic disease:

□Chronic lung disease (asthma, chronic obstructive lung disease etc.)
□Immunodeficiency state (T cell immunodeficiency etc.)　
□Chronic heart disease (congenital heart disease, coronary artery disease etc.)
□Metabolic disease (diabetes) □renal dysfunction □obesity □myasthenia gravis
□Others ( )
□Not taking any medicine
Medicine
 Medicine
□Taking medicine regularly (Specified )

Pregnancy □Yes 　□No

Food Allergies □none

(only for physical □pork □beef □chicken □mutton/lamb □shrimp □crab　□shellfish
reason) □fish □egg □others ( )
Food Restriction □none
(for religion or □pork □beef □chicken □mutton/lamb □shrimp □crab　□shellfish
custom reason)
*Please check the items
□fish □egg □others ( )
even if you're pure *Please be noted that ANSOR will arrange all meals during the program based on the above applied
vegetarian. information and the meals provided in the program cannot meet all the requests from the
participants.
□none
Other Allergies
□dogs □cats □house dust □others ( )
Other Restriction □none
(for religion or
custom reason) □dogs □cats □house dust □others ( )

3. Academic Details/Organization * Please fill in the form in BLOCK LETTERS in English.

Name of School Location: (city,province)
※Only for
UNUSIA Jakarta
Students Bogor, Jawa Barat
Information of your Field of Study or Department
School study Akhalus syahsyi'ah (Hukum Islam)
Grade/School year
*Please fill out also this
part in case you're working 2016 Tel:
students.
Title (for supervisor only)
※Only for Adults Name of Organization Location: (city,province)
Information of your Pergerakan Mahasiswa Islam Indonesia (PMII)
Bogor, Jawa Barat
Organization
Affiliated dept.
*Please fill out also this
part in case you're working Title Tel:
students.
English Proficiency
certificated score (if any, e.g.
TOEFL)
Level of English Level of Bahasa Indonesia
Language Speaking ： Fair Speaking ： Good
Good Fair Poor

Writing ： Fair Writing Good

： Good Fair Poor

Reading ： Fair Reading ： Good

Good Fair Poor

4. Personal Activities * Please fill in the form in BLOCK LETTERS in English.

Activities Period of Involvement

Sports/Clubs balls, tennis and badminton

Hobbies Reading, Writing and Art (calligraphy, painting and drawing

Academic Awards
(if any)

5. Expectations * Please fill in the form in BLOCK LETTERS in English.

Please describe
your expectation by
us domestic. can even talk to the participants and the committee to share and ideas. don't forget I say thank you to the organizers who have held this event, hopefully from this event becom
participating in this
program.
6. Other Information * Please fill in the form in BLOCK LETTERS in English.

Have you ever been to Indonesia before?

Others
If Yes,your visit is financed by
(　　　　　　　　　　　　　　　　　　)

If Yes, when, what was the purpose of

your visit and where did you visit?

If Yes, how long did you stay in

Indonesia ?

1. Declaration
I hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.

Signature: Date: / / (Day/Month/Year)

2. Agreement of the Application Guidelines for Alkahfi Intercultural Festival 2018.

I hereby agree to all the qualifications written in the Application Guidelines for AIF 2018.

Signature: Date: / / (Day/Month/Year)

3. Agreement to handling of personal information.

I hereby agree to the matters stipulated in Application Guidelines with regards to the handling of my personal
information(Annex1).

Signature: Date: / / (Day/Month/Year)

4. Parent/guardian (if applicant is under 18 years of age) :

Signature: Date: / / (Day/Month/Year)