Registration Form - Light the Life Charity Run [INDIVIDUAL]

EARLY BIRD REGISTRATION ENDS AT 13 NOVEMBER 2016, 11:59PM

Registration Fees:
Individual - RM 55 [ Early Bird] | RM 60 [Normal]

You will be entitled with :
T-Shirt | Goodies Bag | E-cert | Medal | Bib

For more information, feel free to contact:
Mois +6016- 661 6047 | Chi Cheng +6017- 726 4393

P/s: This is not a competitive competition :)

Participant's Details
Full Name
Your answer
NRIC / Passport No.
Your answer
Gender
Date of Birth
MM
/
DD
/
YYYY
Nationality
Address
Your answer
Email Address
Your answer
Contact No.
Your answer
Medical Condition
If any, please state below:
T-Shirt Size
Captionless Image
Student's Details*
(Only for UCSI University's Student)
Student ID
Your answer
Course
BA (Hons) Business Administration
Your answer
ELE and ECA
Emergency Contact Details
Full Name
Your answer
Contact No.
Your answer
Relationship
Your answer
Parent's/ Guardian's Details*
( Only for participants below 18 years old)
Full Name
Your answer
NRIC / Passport No.
Your answer
Address
Your answer
Contact No.
Your answer
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