Charity Fun Walk and Fun Run Registration Form
Organized by: ROTARY CLUB OF KINTA

Date: 28 April 2019
Time: 7:00 a.m.
Start/ Finish: Car Park opposite Heritage Hotel

Rotary Club of Kinta, District 3300 is a service organization under the umbrella of Rotary International.
The charity fun walk and fun run are to raise awareness of polio, stroke and healthy lifestyle.
We are supported by National Association of Stroke Malaysia (NASAM), Ipoh branch and Kelab Roadrunners (KRI), Ipoh

Email address *
Event details
1. There are two categories:

a) 3 KM FUN WALK (ONLY for individuals with physical disability and parent(s) bringing along children 12 years old and below)

b) 5 KM FUN RUN (for the general public)

2. Start time:

a) 7:30 a.m. ---> 5 KM
b) 7:45 a.m. ---> 3 KM

3. Entitlement:

a) T-Shirt
b) E- Certificate
c) Goody bag (will be distributed on completion of the walk)

4. Closing Date: 8 April 2019

5. T-Shirt Collection

Date: 23 - 26 April 2019
Time: 2.00 p.m. - 5.00 p.m.
Venue: NASAM, 9 Lorong Pinji, Off Jalan Pasir Puteh
Contact: 05- 3211089 (Miss Jennifer Loke or Mr. Kathiravan)

5. Early bird and normal registration please refer below.

Registration
3 KM Fun Walk Route : Only for individuals with physical disability and parent(s) with children 12 years old and below
5 KM Fun Run Route: General Public
1. Name *
Your answer
2. Address *
Your answer
3. I.C. No. / Passport No. *
Your answer
4. H/P *
Your answer
5. Age *
Your answer
6. T- Shirt Size (picture in Facebook Page) *
T- Shirt Collection
Please refer to the "Event Details" for T-shirt collection.
7. Do you have any physical disability? *
Note:
Kindly fill in question no. 7 a if you have selected "YES" to question no. 7
7. a) If "Yes", please specify the physical disability.
Your answer
8. Are you bringing along children 12 years old and below? *
Note:
Kindly fill in question no. 8a if you have selected "YES" to question no. 8
8.a) If "Yes", how many children are you bringing?
Your answer
9. Are you a student? *
Payment
For payment, please bank in to RHB Bank 20806100018317 (Rotary Club of Kinta) the appropriate amount. Upon completing your payment, please e-mail the payment slip to rckinta.events@gmail.com for us to process your registration. Registration processing will only be done after payment slip has been received.

* Please indicate your name on the payment slip for our reference
Enquiries
If there are any enquiries, please contact us via :

Facebook page: @rckintacharityfunwalknfunrun

Email: rckinta.events@gmail.com

Whatsapp: 016- 6372495
I understand that my registration can only be processed after my payment slip is received by the event organizers. *
Disclaimer
If the event is cancelled or postponed, Rotary Club of Kinta, National Association of Stroke (NASAM) and Kelab Roadrunners Ipoh (KRI) are not liable for any loss or damage incurred by the registrant.

There will be a photographer present and the registrant gives Rotary Club of Kinta, National Association of Stroke (NASAM) and Kelab Roadrunners Ipoh (KRI) permission to use any photos he/she (including children brought along) may appear in, on our website and Facebook page.

Rotary Club of Kinta, National Association of Stroke (NASAM) and Kelab Roadrunners Ipoh (KRI) do not accept any responsibility for, and expressly excludes liability, to the fullest extent permitted by law, for :

(1) any loss or damage to your property during the event;
(2) any death or personal injury suffered by the registrant; and/or
(3) death or personal injury suffered by any child or children brought along by the registrant.
*
Required
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