REGIONAL DISASTER RISK REDUCTION & MANAGEMENT COUNCIL – 7

1ST MUNICIPAL DRRM SUMMIT 2022

REGISTRATION FORM

PERSONAL INFORMATION
Full Name Nickname Gender
Age Date of Birth Weight Height
Civil Status Spouse Diet Restrictions
Residence Mobile No.
Email
Educational Name of School/
Qualification University/Colleges
Training Course:
Allergies/Medications/
Contra-Indications/Fear/
Other Medical, Physical, or
Behavioral Problems
Person to Notify
In case of Emergency
Relationship Contact No.
Address
MEDICAL CERTIFICATION
This is to certify that I have personally examined the above applicant and that I have made the following findings
and recommendation pertinent to his/her participation in Municipal DRRM Summit 2022.
Finding and Recommendations:

Physician M.D.
PRC License No.
Date
LIABILITY RELEASE
I hereby affirm that I am informed and thoroughly aware of the inherent hazards of the 1 st Municipal DRRM
Summit 2022 and that my comfort and safety during such high risks activities shall be my personal responsibility.

In consideration of being allowed to participate in the 1 st Municipal DRRM Summit 2022 and of the benefits
derived thereof, I hereby personally assume all risk in connection with such activity for any harm, injury, or
damage that may befall me, including the released parties, whether passive or active.

I have fully informed myself of the contents of this liability release and express assumption of any burden by
reading it before I signed it on behalf of my heirs and myself.
Signature
Printed Name of Responder
Date
Team Name