Registration Form

Event Date : 29th December 2013 (SUNDAY)

VENUE : Pusat Sumber Alam Sekitar Taman Bagan Lalang, Butterworth REGISTRATION FEE : RM 30 / person

for CYCLING
Flag Off : 7.30am (15KM - on road + off road) Cycling Contact Info : Mr. Ooi 012 - 486 7740 Mr. Goh 019 - 512 2176 Mr. Chan 012 - 454 9189

for SENAM-ROBIK
Start At : 8.30am Senam-robik Contact Info : Ms. Lilian Chung 012 - 422 7229 Ms. YC Tan 016 - 206 3153 Ms. Sherlyn Cheah 012 - 554 8974 Gender : Email : Male / Female

Participant's Information
Name : Address : IC No / Passport No : Club / Team & Location : Contact No : Emergency Contact No/Name : / Relation :

T-shirt Size : S / M / L / XL / XXL / XXXL

Closing date for registration : 30th Nov 2013
LEGAL NOTICE AND DISCLAIMER : Participation in the event is at participant's own risk
The Participant hereby declares warrants & represents to the Organizers that the Participant is 18 years or above. (Participant below the age of 18 is required to complete the Parental Consent section provided below). As a matter of caution, the Participant ought to : 1. Have sought medical examination to ensure that the Participant is certified to be medically fit to participate in the Event; 2. Wherever applicable, have sought to ensure that the Participant is insurance policy is not void or voidable as result of the participant's participation in the Event; 3. Have ensure that Participant's sporting equipments and safety gears have been recently examined by a skilled bicycle mechanic and services and certified to be fit for use in such an Event. 4. Have taken cognizance of the fact that trail designated for this Event is extremely challenging and hence requiring much endurance and technical skill to surmount. I HEREBY DECLARE that I have read and fully understood the terms and conditions of participant in the Event and I participate in the Event at my own accord without any duress and I hereby confirm my unconditional acceptance of the terms and conditions of participation and hereby waive any right of claim against the Organizers, their members, employees, agents or such other parties involved whether directly or indirectly in the preparation, organization and/or management of Pusat Sumber Alam Sekitar, Taman Bagan Lalang Butterworth.

Yours truly, / FOR PARTICIPANT BELOW 18 YEARS OLD

I, , father/mother/legal guardian, hereby acknowledge that I have read and fully understood the terms and conditions of participation in the Event and hereby consent to LOVE GREEN Carnival 13.14's participation in the Event and hereby waive of claim against the Organizers, their members, employees, agents or such other partier involved whether directly or indirectly in the preparation, any right organization and/or management of Pusat Sumber Alam Sekitar, Taman Bagan Lalang Butterworth.

(Signature & Date)

Yours truly, / /

` Signature of Parent/Guardian & IC No & Date

Please bring the reply slip to collect your T-Shirt on :

27/12/13 (Friday 7pm-10pm) OR 28/12/13 (Saturday 1pm-10pm)

Date: Received from: Club / Team : (Name & Chop) Acknowledged by,

T-shirt Size : S / M / L / XL / XXL / XXXL