registration form - Loh Guan Lye Specialist Centre

WORLD HEART DAY WALKATHON
29 SEPTEMBER 2013 (SUNDAY)
REGISTRATION FORM
1.
Name (in full & block)
2.
I/C No. / Passport No.
3.
Sex
5.
Address
6.
Telephone No.
M
F
4.
Date of Birth
Day
7.
Staff / Department ___________________________
8.
Others / Company ___________________________
9.
T.Shirt Size
M
Month
L
Year
XL
NEXT STEP
I, the abovenamed hereby enclose RM ………………………………(cash only) as my entry fee & agree to abide by the conditions & rules of
the walk, I certify that the details given above are correct & I am physically fit & sufficiently trained to finish the Walk. I will attempt
to complete the Walk within the limit.
Athlete's Waiver/Indemnity : In consideration of the Organiser accepting this entry, I upon entry & registration to participate in the
above Walkathon, hereby for myself, my heirs, executors & administrators, waive & release any & all rights or damages I may have
against the Organisers holding this walkathon, their representatives, asignees, sponsors & co-sponsors for all injuries, death & invalidity
I may sustain during the course of the event or arising as a result of it. I hereby indemnify & keep you indemnified & waived against
all claims or damages that may arise in consequence of the above.
……………………………………………..
Date
…………………………………………………………..
Participant's Signature
For Participants Under 18 Years Of Age
I parent/guardian of the participant, whose particulars appear above, confirm, that I fully understand & appreciate the effect of the
above waiver & hereby agree & declare on behalf of the participant that the purport of the Waiver Clause will have equal binding
effect on the participant.
I hereby consent to his/her participation in the above walkathon.
Name: ………………………………………………………………………………………………………………………
I/C No. …………………………………………………………………………………
Date: ………………………………………….
…………………………………………………………..
Signature of Parent / Guardian
RULES, REGULATIONS & PAYMENT RECEIPT
This walk is open to staff of LohGuanLye SPECIALISTS CENTRE (LSC), their family members and the general public.
Entry Forms can be downloaded from www.lohguanlye.com and also available at LSC Reception Counter,
Main Wing (B3, Macalister Road). Closing date for registration is 14 September 2013. Late entries will not be entertained.
The registration fee is RM 20.00 per pax (Includes T-shirt & Goodie Bag).
Please collect your T-shirt at LSC Reception Counter (B3, Main Wing) between 19 to 20 September 2013 (10am to 4pm)
or 21 September 2013 (10am to 1pm).
Participants are to assemble at the LohGuanLye SPECIALISTS CENTRE (B3, Main Wing). The reporting time is 6am sharp.
The Management of LohGuanLye SPECIALISTS CENTRE wish to thank everyone for their valued participation in making this
World Heart Day Walkathon a success.
Payment received on:………………………………
Received by:……………………………………….