Rafflesia Holiday Programme

Holiday Programme Registration Form

I want to join:

SMR Holiday Programme@Kajang

SRR Holiday Programme@Puchong

(for children aged 12- 14)

(for children aged 6 12)

Student Name: ________________________________________________________________

(please write clearly)
IC No / Birth Certificate No: ______________________________________________________
Gender:

Male

Female

Date of birth: ____________________

Place of birth: ____________________________

Existing Schools: _____________________________________________________________

Name of Father:______________________________________________________________
Fathers office number: ________________________ Fathers H/P: _____________________
Fathers Email: ______________________________________________________________
Name of Mother:______________________________________________________________
Mothers office number: ________________________Mothers H/P: _____________________
Mothers Email: ______________________________________________________________
House Address: _____________________________________________________________
Postcode: _______________________________

State: ___________________________

Home number: ___________________________

H/P: ___________________________

Emergency Contact (In case of both parents are uncontactable)

Name: _______________________________________________________________________
Contact Number: _____________________________ Relationship: _______________________

Medical Details
Allergies/asthma/serious illness/injuries or special needs/ dietary requirements or issues:
_______________________________________________________________________
_______________________________________________________________________
Description of any current medications and instructions for administering if required.
_______________________________________________________________________
_______________________________________________________________________
Please indicate child Swimming Ability: Strong / Moderate / Learner / Cant Swim
Please ensure your child is appropriately dressed for the activities. Rafflesia takes no responsibility for
lost or stolen property.
Terms and Conditions
1. In case of emergency, I allow my child to be given First Aid treatment by the programme staff. Parents
will be notified immediately if the child is taken to the hospital.
2. I, hereby, agree and permit the school to use any images, stills or video of my child for future
publications and media purposes. If I wish to withdraw this permission, I will notify the school with a
written notice.
3. I understand that the claimable amount, in case of any accident, shall be the amount insured.
4. I shall not hold Rafflesia liable due to my childs negligent and misconduct in the duration of the camp.
5. I, hereby, agree and understand the terms and conditions as mentioned above.

Parents Signature

Name:
Date: