Young Girls' Empowerment & Leadership Bootcamp 2020 Participant Registration Form

Young Girls' Empowerment & Leadership Bootcamp 2020 Participant Registration Form
Please fill the form below keenly and let us know if you give go ahead for this participation

Participants Personal Particulars
Participant full name as per NRIC*
First NameLast Name
NRIC No*
Participant address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Mobile Phone*
Area CodePhone Number
E-mail
Date of Birth*
MonthDayYear
Age*
Name of the school/college/university*
T-shirt size
SMLXL2XL3XL
Ambition

Parents Contact Information
Father's name*
First NameLast Name
Father's NRIC No*
Father's occupation*
Mother's name*
First NameLast Name
Mother's NRIC No*
Mother's occupation*
Number of family member
Household income (jumlah pendapatan isi keluarga)
Mobile No (Father)*
Area CodePhone Number
House No (Mother)*
Area CodePhone Number
Office No
Area CodePhone Number

Guardian Contact Information
Guardian's name
First NameLast Name
Guardian's NRIC No
Guardian's occupation
Guardian's relationship to participant*
Mobile No*
Area CodePhone Number
Office No
Area CodePhone Number

Medical Declaration
Does your child have a life-threatening health condition?*
YesNoOther
Is your child under medication currently?*
YesNoOther
Does your child have any food allergies?*
YesNoOther
Does your child have any diet preferences such as vegan, vegetarian, pescatarian or etc ?*
YesNoOther

COVID-19 Declaration
Please declare if you or any of your immediate family member was tested positive for COVID-19 in the last 90 days?*
YesNoOther
Did you travel to any country in the last 90 days?*
YesNoOther

Location for Phase 1-3
Which state do you prefer to join?*
Negeri SembilanPenang
Please be informed that Final Phase (3 days 2 nights) will take place in Penang
All participant compulsory to attend to receive their certificates.

Sign
Parents/Guardian Name*
First NameLast Name
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Registration date*
MonthDayYear
Date
I confirm that I am the parent/legal guardian of (Participant’s Name) (Participant’s NRIC) to participate in Young Women Empowerment Bootcamp and Young Women Leadership Bootcamp 2020.
Signature
Clear
Should be Empty: