EmailMe Form - “为爱而跑”义跑筹募活动 - 报名表

“为爱而跑”义跑筹募活动 - 报名表

Charity Run Registration Form

【Information 资讯】

Organizer 主办单位：
Church of Holy Name of Mary Charity Run Committee
圣母圣名堂为爱而跑筹委会

Aim 宗旨：
1. 为提倡筹款于圣安纳洗肾中心及圣母圣名堂仁爱基金
To raise the fund for St.Anne Haemodialysis Centre and Welfare
Fund for Parish Church of Holy Name of Mary.

Date 日期：
23-08-2014 ( Saturday )

Time 时间：
6.00 A.M – 12.00 P.M

Venue 地点：
Church of Holy Name of Mary, Permatang Tinngi
峇冬丁宜圣母圣名堂

Registration Fees 报名费：
RM20.00
(Goodies Bag are limited to first 1000 participant)

Distance 路程：
10 KM

Participation 参加资格：
Open to Malaysian 大马公民

Closing Date 截止日期：
27-07-2014

Enquiries 询问：
Nigel Lai 赖君国 017-428 6620

Register 报名：
Mary Anne 011-1655 8153
Celine Yee 余莹莹 016-494 8776
Teh Lisa 郑丽莎 017-593 9763
Holy name of Mary parish office
圣堂办公室 04-5887799

Full Name 全名 *
Please write in English
请写出英文名，必须和身份证上的名字一样
IC/Birth Cert.no
身份证/报生纸号码 *
Date of Birth生日日期 *
MM / DD / YYYY
Age 年龄 *
Gender 性别 *
Male 男
Female 女
Contact No. (H/P)
联络号码 (手机) *
Contact No.(Home)
联络号码 (家里)
E-mail *
Address 地址 *
Category 组别 *
Men (18 & above) 男子公开组（18岁以上）
Men (Below 18) 男子青年组（18岁以下）
Women (18 & above) 女子公开组（18岁以上）
Women (Below 18) 女子青年组
Waiver Clause
I, the participant, hereby agree to abide by the rule and conditions of the Run Event. I certify all of the above particulars are correct. I am entering the Run Event at my own risk shall not hold the organizer responsible for any accident/injury/death/loss of property, however caused before, during or after the Run Event.
*
Im agree for the term above
Authorization by parent / guardian of participants under 18 years
18岁以下家长/监护人同意书
Im agree the participant below 18 years old authorize participation in the Run Event.
家长姓名
Parent's Name
Please write in English
请写出英文名，必须和身份证上的名字一样
家长身份证号码
Parent's IC no.
家长联络号码
Parent's Contact No.
凡是18岁以下的参加者，如果没有给足以上这资料将不被接受报名。
For participant under 18 years, we din't allow to register if din't fulfill the information above.
Remittances 汇款方式

银行 Bank :
Public Bank 大众银行
Account Name : Boo Rui Xiu
Account Number : 3-1879442-13

*汇款后请拍下Receipt或Scan或Print screen，然后上传。
Please attach the file [Scan the receipt/snap photo/print screen(for transfer)] after remittance.
Receipt Remittance 汇款收据 *

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