2012年边佳兰儒艮杯义山行 | 2012 Jogathon Warisan Piala Dugong Pengerang

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Date: 4 / 11 / 2012 (Sunday)
Time:6.30AM Gathering,7AM Start
Venue:Tokong Cina,Kampung Jawa Pengerang-边佳兰头湾护福庙
Distance:5KM
Registration Fee: RM 20 (Free 1 T-Shirt)

姓名

(中文)

NAME *

AS IN NRIC* (PLEASE FILL IN CAPITAL LETTERS)

性别 /Gender *

男/ MALE

女/ FEMALE

身份证号码 / NRIC NO. *

NRIC NO.* (XXXXXX-XX-XXXX)

生日日期 / BIRTHDAY *

(DD-MM-YYYY)

联络号码 / CONTACT NO. *

(60XXXXXXXXX)

电邮地址 /Email *

住址 / Current Address *

紧急联络人 / EMERGENCY CONTACT PERSON *

(PLEASE FILL IN CAPITAL LETTERS)

紧急联络号码 / / EMERGENCY CONTACT NO. *

(60XXXXXXXXX)

参赛组别/Category *

注意 / Attention: 欢乐组不设奖金奖品/Fun run group no award for prize -活动盈余将全数捐助边佳兰自救联盟作为活动经费/All surplus will be funding to Pengerang SOS

A:公开-男 / OPEN - MAN-RM20

B:公开-女 / OPEN - WOMAN-RM20

C:乐活/ FUN RUN-RM20

衣服尺码/Size *

28(children size)

32(children size)

XS(36)

S(38)

M(40)

L(42)

XL(44)

XXL(46)

免责声明 / Waiver Clause *

我兹证明以上资料确实无误，并愿意遵守主办单位的所有规则。若在比赛前、比赛期间或比赛后发生任何意外，一概由本人自己负责。I hereby declare that I am medically fit and I am entering the event at my own risk and will not hold this organizing committee responsible for any injuries for accidents which may incur before, during and after the event. I have read and agree to abide by the Rules and Regulations of the Jogathon Warisan 2012.

Required

付款事项/Payment Notice

*参赛资格在赛前付款后方才生效。(Payment must be settled before the event)

*报名费可以以现款/划线支票/汇款付款至: ( Payment can be made by Cash / Cheque / Cash Deposit / GIRO to )

收款人/ Payee: The KL & Selangor Chinese Assembly Hall （大众银行/ Public Bank: 3-0771383-10）

*请将报名表格及汇款收据传真/电邮/邮寄至隆雪华堂秘书处。 (Please fax/E-mail/post entry form and proof-of-payment to KLSCAH Secretariat)
Tel: 03-2274 6645 | Fax: 03-2272 4089 | E-mail: info@malaysiayouth.com | Address: No.1, Jalan Maharajalela, 50150 Kuala Lumpur.
（请注明/Pls note: 2012年边佳兰儒艮杯义山行/Jogathon Warisan Piala Dugong Pengerang 2012）

*住在雪隆一带的报名者，可以到隆雪华堂索取T-Shirt。
Participants in Klang valley can collect T-Shirt in KLSCAH,

*其他地方的网上报名者，请保留银行收据，以在义山行当天到柜台索取T-Shirt。
Participants from other states can collect T-shirt on the spot by showing the bank in slips as prove of registration fee has been paid.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms