Aspiring Doctors - Registration Form
Date of Event: 30 November 2019
Time: 10:00 am - 4:00 pm
Venue: RCSI & UCD Malaysia Campus, 4 Jalan Sepoy Lines, 10450 George Town, Penang, Malaysia

Registration Fee: RM 50.00 per person

For event enquiries, please email events@rcsiucd.edu.my

RUMC adheres strictly to GDPR policies to ensure personal data protection of its clients. All data filled within this form will only be used by RUMC networking purposes only.
STUDENT DETAILS - AS PER NRIC/PASSPORT
Please complete this registration form in CAPITAL LETTERS
Full Name: *
Your answer
Gender: *
Age: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Mobile No: *
Your answer
Email: *
Your answer
PARENT/GUARDIAN CONTACT INFORMATION
ONLY TO BE COMPLETED IF PARTICIPANT IS UNDER THE AGE OF 18
Full Name:
Your answer
Gender:
Relationship:
Your answer
Mobile No:
Your answer
Email:
Your answer
ACADEMIC DETAILS
Name of Current School/College: *
Your answer
Current Study Level: *
Location of Current School/College *
Your answer
How Did You Find Out About This Program? *
Dietary Requirements: *
PAYMENT INSTRUCTION:
1. Payment is to be made via online banking/transfer to the following bank details:

ACCOUNT NAME: PENANG MEDICAL COLLEGE SDN. BHD.
BANK NAME: CIMB ISLAMIC BANK BERHAD
BRANCH: PULAU TIKUS BRANCH, 409, JALAN BURMA, 10350 PENANG
ACCOUNT NO: 8602 154 353
SWIFT CODE: CTBBMYKL

2. You will receive a confirmation email from the organiser once your registration is received.
3. A copy of the payment receipt will be issued at the registration counter on the event day.
DISCLAIMER
1. The organisers may at any time, with or without giving notice, in their absolute discretion and without giving any reason, cancel or postpone the Aspiring Doctors event, change its venue or any of the other published particulars, or withdraw any invitation to attend.
2. By agreeing to the Terms and Conditions, you agree to indemnify RCSI & UCD Malaysia Campus and its organisers, officers, employees, agents, volunteers, members or representatives, from any loss, liability, damage or expense suffered or incurred by any person.
3. All fees paid for the participation in the Aspiring Doctors event are not refundable under any circumstances.
DECLARATION BY APPLICANT
By clicking submit you agree to the following:

1. I hereby verify that all information given in this registration form is complete, true and accurate to the best of my knowledge.
2. I hereby agree that RCSI & UCD Malaysia Campus has the right to reverse any decision in respect of my registration, in the event that the information given is found to be incomplete, inaccurate or false.
3. I authorise RCSI & UCD Malaysia Campus to communicate with my parent or guardian any information pertaining to the Aspiring Doctors event.
4. I confirm that I have read and understood the Terms and Conditions of this registration form.
Submit
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