IMU 20th Anniversary Celebration Registration Form (Competition)

Date : 14th April 2012 (Saturday) Flag Off: SHARP 7.30 am Venue : Dataran Penggaram, Batu Pahat Registration Fees: RM30 Contacts: Canace Teoh (0132083265) Tan Wei Sheng (0127681963)

Jom Kayuh 2012

Closing Date: 30th March 2012 Cycling Competition Route: https://www.facebook.com/JomKayuhBatuPahat For safety reasons, please wear a bicycle helmet. APPLICANT INFORMATION Name: Address: Tel/Mobile: IC Number: EMERGENCY CONTACTS Name: Contact Number 1: Relationship: Contact Number 2: PRIZES 1st 2nd 3rd First 100 (Men&Women) MEN RM 350 RM 250 RM 100 WOMEN RM 200 RM 100 RM 50 E-mail Address: T-shirt Size: S / M / L / XL / XXL / XXXL Age: Gender: Male / Female

PAYMENT METHOD 1) Pay directly to IMU office at: IMU Clinical School Batu Pahat 12, Jalan Indah, Taman Sri Kenangan, 83000 Batu Pahat, Johor. 2) Bank in your payment to the following account and fax your bank in slip with filled registration form to +6074325575 or email to imu20batupahat@gmail.com

Finishing Medal

3) IMU Bank Account: Maybank 5141-8742-7455

(IMU Education Sdn Bhd) 4) Bring along registration form/bank slip to collect on the day of event.

All participant

Certification of Completion

Completed online forms can be returned to IMU Clinical School Batu Pahat or email to

imu20batupahat@gmail.com Please check the name list at : https://www.facebook.com/JomKayuhBatuPahat LEGAL NOTICE AND DISCLAIMER PARTICIPANTS IN THIS EVENT ARE AT THEIR OWN RISK The Participant hereby declares warrants and represents to Organizer that they are 18 years old and above. As matter of caution, participants are ought to: 1) Sought medical examination ensured that participant is certified to be medically fit to participate in this event. 2) Wherever applicable, ought to ensure that participants insurance policy is not void or voidable as a result of the participation in this event. 3) Have ensure that participant sporting equipment and safety gears have recently check by skilled bicycle mechanic in event and services to be fit for use in this event. 4) Have taken cognizance of fact that the trail designated for this event is extremely challenging and hence required much endurance and technical skill to surmount. I HEREBY DECLARE that I have read and fully understood the terms and conditions of the event at my own risk and accord without any duress and I hereby confirm unconditional acceptance of terms and conditions of participation and hereby waive any right of claim against the Organizer, members, employees, agent or such other parties involved whether directly or indirectly in the preparation, organization and management of the event by International Medial University. Yours truly, _________________ Signature/Name Date: