REGISTRATION FORM 2014

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DETAILS

1) DATE : 20 SEPTEMBER 2014 (SATURDAY)
2) VENUE : TAMAN TASIK TITIWANGSA,
Jalan Tembeling, 53200 Kuala Lumpur.
3) TIME : 7.30AM- 9.30AM
4) ORGANIZER : PHYSIOTHERAPY CLUB,
THE NATIONAL UNIVERSITY OF MALAYSIA
(UKM)
5) CATEGORY :
Category Distance Normal Fee
A Preschool children,
People with disability (OKU), 2.5km FREE
Older adults aged 60 and above.
B Others 2.5km RM5

6) REGISTRATION FEE : Registration fee is not refundable.
7) Participants with cardiological history are advised to consult your doctor prior registration.

FULL NAME (BLOCK LETTER) *

I/C NO *

SEX *

MALE

FEMALE

Required

DATE OF BIRTH *

YYYY

AGE *

CONTACT NO. *

CATEGORY *

MAILING ADDRESS *

POSTCODE *

NATIONALITY *

EMAIL ADDRESS *

WAIVER CLAUSE *

In consideration of the Organizer accepting this entry, and registration to participate in the above Walk, I hereby waive and release any and all right or claims to damages I may against the Organizers holding this Walk, their agents, representatives, successors, assigns, race sponsors for any and all injuries, death and invalidity I may sustain before, during or after the course of the event or arising as a result of it. I hereby indemnify the Organizers and keep them indemnified and waived against all claims or damages that arise in consequence of the above.

Required

FOR PARTICIPANTS UNDER 18 YEARS

As the parent / guardian of the participant, whose particulars appear above, comfirm that I fully understand and appreciate the effect of the above waiver and hereby agree and declare on behalf of the participant That the Waiver Clause will have been binding affect on the participant. I hereby consent to his/ her participation in the Walk as stated above. *** Please fill up the parent/ guardian's details below.

PARENT/ GUARDIAN'S FULL NAME

* Only for participants who are under 18 years old

PARENT/ GUARDIAN'S I/C NO.

* Only for participants who are under 18 years old

PARENT/ GUARDIAN'S CONTACT NO.

* Only for participants who are under 18 years old

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