Camp Leader Registration

* = mandatory field ** = either field is required Chinese character is not acceptable       IC ** Passport no. ** Title * Mr Ms Mrs Mdm Dr Given Name * Family Name * Age (18 and above) * Gender * Male Female Camp Language * Chinese English Chinese & English Camp Category * Public Kindergarten Primary school Secondary school Corporate Religious Institution Social Association University/College Organisation Represented (if applicable) Address line 1 * Address line 2 Address line 3 Town/City * Postcode * State * Johor Kedah Kelantan Kuala Lumpur Labuan Melaka Negeri Sembilan Pahang Perak Perlis Pulau Pinang Putrajaya Sabah Sarawak Selangor Terengganu Others (International) Home no. ** Office no. ** Handphone no. ** Fax no. Email * How did you hear about the Famine * DIY Camp Leaders Mailer posted by World Vision Email sent by World Vision Websites (World Vision or others) Social Media (blog, Facebook, etc) Newspapers - Chinese Newspapers - English 8TV Radio_MY FM Radio_Mix FM Magazines Word of Mouth Churches Event/Others Pls Specify First Referral's Name * First Referral's Organisation * First Referral's Position * First Referral's Contact no * First Referral's Email * Second Referral's Name * Second Referral's Organisation * Second Referral's Position * Second Referral's Contact no * Second Referral's Email * Preferred training workshop * 08 May 2010 (Sat) - Kuala Lumpur 15 May 2010 (Sat) - Penang 16 May 2010 (Sun) - Ipoh 22 May 2010 (Sat) - Johor Bahru 29 May 2010 (Sat) - Kuantan 12 Jun 2010 (Sat) - Kuala Lumpur Estimated camp size * 10-20 21-50 51-100 101-200 201-300 Others Pls Specify Target Camp Location (building name, address, if available) Target Camp State * Johor Kedah Kelantan Kuala Lumpur Labuan Melaka Negeri Sembilan Pahang Perak Perlis Pulau Pinang Putrajaya Sabah Sarawak Selangor Terengganu Others (International) DIY Camp Date Registration Closing Date Committee who are coming for training (10 max, include Camp Leader) * 1 2 3 4 5 6 7 8 9 10 Will your camp be open to the public * Yes No First time organising DIY Camp ? * Yes No     I hereby agree to abide by the rules and regulations of the 30-Hour Famine. I declare that I am medically fit and am participating in this event at my own risk and will not hold the Organisers responsible for any injuries, death and other losses or damages that may be sustained before, during and after the event. I further undertake to indemnify you and keep you indemnified against any claims that may be brought against you in respect of the above. Expectant mothers, people suffering from diabetes, gastric, ulcers, heart disease and hypertension should first obtain certification from qualified medical doctors. Campers 12 years old and below must be accompanied by a parent/guardian. 本人在此同意接受并遵守“饥饿30”所订下的条规与免责声明。本人身体健康,没有传染病或各种不适宜参加此活动的疾病。本人同意此活动属自费自愿参加形式。活动中若有任何伤亡意外或财物损失,主办当局无需承担任何事前、事发及事后的赔偿责任。孕妇、糖尿病、胃病、溃疡、心脏病以及高血压与自行禁食者,必须向医生问取意见和健康证明书,12岁或以下的儿童须由一名长辈陪同参加。