PARI SAKTI DIVING INTERNATIONAL COMPETITION

GBK Aqua c Stadium Senayan, Jakarta, Indonesia

16 – 18 May 2024

FINAL ENTRY FORM

( Please return by 15th April 2024 to : parisak dv.organizer@gmail.com )

1 Team Name : Be er Diving Club

2 Contact Person : Muharam Saribi
3 Phone Number : 082113096242
4 Email : be erdivingindonesia@gmail.com

ENTRY LIST
 OPEN
D.o.B Gender
Name 1M 3M Pla orm
(dd/mm/yy) M F
Heuasal Latupono 03/06/06 X X
Jesica Diva Salsabila 23/01/08 X X X X
Nur Haniyah 03/04/08 X X

1
- Final Entry Form -
 AGE GROUP B ( 14 or 15 year on 31st December 2024)
D.o.B Gender
Name 1M 3M Pla orm
(dd/mm/yy) M F
Risky Aditya Harith 12/08/10 X X X X
Niken Aulia Chuana 16/01/10 X X X

 AGE GROUP C ( 12 or 13 year on 31st December 2024)

D.o.B Gender
Name 1M 3M Pla orm
(dd/mm/yy) M F

 AGE GROUP D ( 11 year and below on 31st December 2024)

D.o.B Gender
Name 1M 3M
(dd/mm/yy) M F
Muhammad Alkhalifi Rahman 21/03/14 X X X

2
- Final Entry Form -
 NOVICE A
D.o.B Gender
Name 1M 3M 5M
(dd/mm/yy) M F

 NOVICE B
D.o.B Gender
Name 1M 3M 5M
(dd/mm/yy) M F

 NOVICE C
D.o.B Gender
Name 1M 3M
(dd/mm/yy) M F

3
- Final Entry Form -
 LIST OF COACHES, TEAM MANAGER, JUDGE, ETC.
Gender D.o.B
No Name Title
M F (dd/mm/yy)
A Rafiq X manager
Sugeng Riyadi X Judge
Muharam Saribi X Coach

Submi ed by
Name : Muharam Saribi
Designa on :

Signature :

Seal :

Date (dd/mm/yyyy) : 15/03/2024

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- Final Entry Form -