‘SECRET OF SUCCESS’ MUSIC CAMP

REGISTRATION FORM
JAY’S ONLINE MUSIC (JOM)
in collaboration with
PERSATUAN ERA REVOLUSI MUZIK

INSTRUCTIONS

1. Complete this form in BLOCK letters.

2. Submit this form latest by 8TH DECEMBER.
3. Please attach a CLEAR COPY of your Image and NRIC in the requested areas.
4. Completed Application Form must be sent to Ms. Tarrsini @ +0163714399 before the date
mentioned above.
5. Please attach a copy of your NRIC/PASSPORT along with this document during submission.

PERSONAL PARTICULAR

Full name* : UAMA THEVI A/P THEVARAJ

Desired Name Tag*: UamaGreat

Date of Birth* : 15.04.1974

Place of Birth* : KULIM KEDAH

Gender* : ☐ MALE ☒ FEMALE

Insert Your Picture Here
(PNG/JPEG)
Marital Status* : MARRIED

Nationality* : MALAYSIAN

NRIC Number* : 740415025634

Passport Number* :
A54307555

1. CONTACT DETAILS

NO. 9 , JALAN SEMPALIT PERMAI 6 ,

 Permanent / Home Address* :

TAMAN SEMPALIT PERMAI , 28400 MENTAKAB

PAHANG DARUL MAKMUR

Phone Number* : 019 - 9555634

Email Address* :
uma.great74@gmail.com

EMERGENCY CONTACTS
Name* : K. THASHAKAUSALYA

Relationship* : DAUGHTER

Contact Number* : 018-9710345

2. DIETARY RESTRICTIONS

Please choose your preferred meal option. *

☐ VEGETARIAN ☒ NON-VEGETARIAN ☐ OTHERS:

Do you have any allergies or medical condition*? ☐ YES ☒ NO

If yes, add specifications:

Are you consuming any medications right now*? ☐ YES ☒ NO

If yes, add specifications:

Have you been tested COVID Positive recently? * ☐ YES ☒ NO

If YES, have you completed your quarantine period? * ☐ YES ☐ NO

3. INFORMATION

Song Chosen For Camp*: NIL

Movie Name* : NIL

Root Note* : NIL

Do you have your Minus-One and Original song link/audio? * ☐ YES ☐ NO

 T-Shirt Size* : ☐ XS ☐ S ☐ M ☐ L ☐ XL ☒ 2XL ☐ 3XL ☐ 5XL ☐ 6XL ☐ 7XL
*Please refer to the image given in Whatsapp for measurements.

Have you submitted a copy of your NRIC/PASSPORT along with this document? *
☒ YES ☐ NO

DECLARATION

1. I declare that all information given above is complete and accurate.  

2. I understand that I NEED TO FOLLOW the constitution and bylaws and to further follow all the
instructions and rules given by those responsible for or in charge of any activities while I am
participating in this camp.
3. I understand that JOM, their employees, coaches/instructors, trainers, mentors, directors,
members and representatives, are not responsible for any injury, loss or damage of any kind
sustained during the entire duration of this camp.
4. In consideration of my participation in the 'Secret of Success Music Camp', I acknowledge that
I am aware of the possible risks, dangers and hazards associated with my participation,
(including the possible risk of severe injury to myself or others). These risks include but are
not limited to the following:
a) The risks associated with travel to and from location(s) to be visited during the camp,
including transportation provided by commercial, private and/or public motor vehicles.
b) The possibility of bodily injury including dental damages whether caused by myself or
someone else;
c) The risks associated with coming from or returning to my residence .

To be signed during the registration day, 17th.

NAME : UAMA THEVI A/P THEVARAJ

DATE: 17.12.2022

NRIC/PASSPORT NUMBER : 740415-02-5634