White Water Summer Camp

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Geraldine Harrell
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White Water Summer Camp 2018 Registration Form Camp dates: 17-22 December 2018 Venue: Murni Camp Gopeng, Perak Registration closing date: 30 Nov 2018 Camp fee: Eligibility: RM 680 (early bird -

1 White Water Summer Camp 2018 Registration Form Camp dates: December 2018 Venue: Murni Camp Gopeng, Perak Registration closing date: 30 Nov 2018 Camp fee: Eligibility: RM 680 (early bird - before 21 Oct 2018); RM 780 (normal); or RM 730 (sibling price - per pax) years old Please enclose a photo of yourself and attach a photocopy of your MyKad/passport ID with this completed enrolment form and either: i) scan and the form to registration@wwsc.org.my along with a digital photo and IC/passport ID; or ii) post it to 10B&C, Jalan PJS 7/3a, Bandar Sunway, Petaling Jaya, Selangor with an attached passport photo and a photocopy IC/passport ID Part 1. Camper s details (as in birth cert/mykad) MyKad no./passport no.: Gender: Male Female Date of birth: - - Religious status: Telephone no. (home): Home address: Mobile no.: School: How did you come to know us? Website Social Media Referral Others: Facebook Family ( ) Instagram Friends ( ) Language(s) spoken: Proficiency Level: Please tick the relevant box(es) English (Low) (High) Bahasa Malaysia Mandarin Others: Please specify your dietary requirements: Vegan Vegetarian Non-spicy food Others: Part 2. Getting to know you! :) tell us more about: Your interests - what you're passionate about, your likes and hobbies. What you think is most important in life? Your goals and aspirations.

2 Part 3. Emergency Contact MyKad no./passport no.: Relationship with camper: Telephone no. (home): Telephone no. (office): Address: Mobile no.: Part 4. Medical history and background *Weight & Height information is required to be filled in for safety purposes Weight in kilograms: kg Height in centimeters: cm *Head & Chest circumference information is required to be filled for helmet and life jacket fit Head circumferences Chest circumference cm cm Can you swim? If YES, please indicate your level of mastery: Yes No Novice Intermediate Advanced Have you been immunised against If YES, approximate date of last booster: Diphtheria, Pertusis & Tetanus Yes No Don't know - - Hepatitis B Yes No Don't know - - Tuberculosis (BCG) Yes No Don't know - - Measles, Mumps & Rubella Yes No Don't know - - Most children would have completed the immunisation listed above by age 7. If you are unsure, you should check with your physician to ensure that you are fully vaccinated and protected against these common pathogens before coming to camp. Please tick where applicable: Injury to any muscle, joint or bone Yes No Injuries or surgery (minor/major) in the last year Yes No Allergies e.g. bee sting, drugs, foods Yes No Asthma / breathing difficulties Yes No Motion sickness Yes No Convulsions, fits or epilepsy Yes No Psychological/behavioural problems Yes No Diabetes Yes No Migraine or severe headaches Yes No Any other conditions (e.g. G6PD, Thalassemia etc.) Yes No If you answered YES to any of these questions, please give details in the space provided and state whether any current or past condition might be of concern during the camp. Kindly attach all certified medical records pertaining to your condition (if any), past injuries/surgeries (if any) and include proof of immunisation that is certified by a certified medical practitioner. If you ticked YES for "Allergies", kindly state the allergy and the allergic reaction Allergy Allergic reaction

3 If you are taking prescribed medication of any type, you are required to bring an adequate supply of them for the duration of the camp and notify the camp health officer or physician as soon as you arrive. All prescribed medication will be collected and dispensed by camp Pharmacists or Doctor. Non-provision of essential personal medication could result in removal from the program. We recommend bringing up to twice the amount of medication normally needed. Family physician to be contacted in case of emergency: Phone number Part 5. Transport Please select your preferred transportation arrangement By transport provided by WWSC: From a public pick-up point to campsite From campsite to a public pick-up point By own transportation: To campsite From campsite More information will be sent to campers a week before the camp begins. Part 6. Parent/Guardian Consent & Indemnity Form I hereby consent my child/ward to attend and participate fully in all activities organised in Murni Camp Gopeng from December 2018 ("camp") on the terms and conditions herein. I understand that this camp is organized by White Water Summer Camp (WWSC) ("the Organizer"), a non-profit organisation and is run by its partners, directors, trainers, instructors and staff members, all of which is approved and authorised by the Organizer (all the aforementioned shall hereinafter be collectively referred to as the Persons ). I, (MyKad no./passport no. ), parent/guardian of (MyKad no./passport no. ) agree to and hereby declare as follows: 1. I give permission for appropriate actions to be taken should any medical emergencies occur and authorise any trained Person to perform first aid medical treatment at the camp should it be necessary. I authorise any Person to give permission to a hospital or medical doctor to perform any necessary treatment/procedures in the case of an emergency. I further authorise the hospital or clinic to release my child/ward's medical report(s) to the Person for insurance claim purposes (if applicable). Should any medical costs be incurred and my child/ward's insurance does not cover the costs, it is and will be my responsibility to bear all costs incurred. 2. I understand that the Organizer will keep a record of my child/ward's personal details, and will use this information for internal administration and participation, and may contact me about WWSC and any associated activities I agree that the Organizer may use and publish photographs taken, any form of artwork and written work as well as video and audiotape created as part of participation in this camp. The organisation may use these items in the production of educational or promotional materials. These items may be used and published with my child/ward's first name (or nickname) and age. I give my child/ward consent to participate in swimming, white water rafting and other water activities organized by the Organizer. If my child/ward is not a good swimmer, my child/ward is hereby strongly advised by the Organizer to enrol for the necessary swimming lessons prior to the commencement of the camp. I am aware that the Organizer will be conducting a swim test for all participants of the camp to assess their swimming ability. Should my child/ward fail this test, I authorise that he/she to be barred from all water activities that are deemed unfit for his/her undertaking. 5. I am aware that my child/ward's attendance in this camp involves a certain degree of risks. I am aware that this camp involves adventurous outdoor activities in which my child/ward may have no previous experience, and which may demand physical and mental effort in a variety of weather conditions and in remote geographic circumstances. I am also aware that in allowing my child/ward to participate in this camp s

4 program and activities, I understand that I am and will be held liable as a parent/legal guardian. I have carefully considered the risk involved and have given consent for my child to participate in all the activities organized in by the Organizer. I also understand that participation in this camp is entirely voluntary and my son/daughter will abide by all rules, instructions and regulations set by the Organizer. 6. With this release and indemnity and in consideration of the enrolment, I understand and agree that although health and safety precautions will be taken for campers at camp, I will not hold any of the Persons liable and hereby release the Persons from and indemnify them against any and/or all claims, actions, liabilities, losses, costs, expense or exhortations in any form whatsoever arising out of this camp and in relation to the death of, illness, personal injury, property damage or any other loss to my child/ward howsoever arising from this camp, including but not limited to negligence of any of the individuals and whether within or without camp grounds, unless caused by the wilful misconduct or gross negligence on the part of the individuals. 7. I declare that my child/ward is medically fit to attend the camp, and that he/she does not pose any threat or risk to either him/herself orthe other campers. Should any medical condition exist, I undertake to notify the Organizer of it by filling in the appropriate section of Part 4 of this form, and to ensure adequate and proper provision of all necessary medication and/or treatments with my child/ward for the duration of the camp. 8. For the smooth running and safety of the camp, I understand that my child/ward will abide by all rules, instructions and regulations of which he/she will be informed of at camp. I understand that he/she will have to cooperate fully with the Persons and diligently comply with all the safety requirements. Should my child/ward fail to do so, I hereby authorize that arrangements be made to remove him/her from camp and I shall be responsible for all expenses incurred for his/her transportation home. 9. I undertake to inform and instruct my child/ward to immediately notify any Persons should any circumstances/conditions during the course of the camp change in such a way that it poses a danger to my child/ward's health and/or safety. 10. I further indemnify any Persons against any claim and/or action or exhortation instituted against them because of action, omission or neglect on my child/ward if such action, omission or neglect caused damage, loss, illness, personal injury or death to a third party or persons, including other campers. Likewise, if my child/ward is hurt by the actions, omission or neglect of another individual, I will exempt and release the Persons and hold the other individual or his/her parents responsible. 11. Should my child/ward make use of any transport other than his/her own, either to or from the camp premises, or during the camp, I exempt and release the Persons from any action, claim, exhortation and/or liability in respect of any damage, personal injury, death or loss suffered by my child/ward whilst making use of such transport. 12. The releases, indemnities and undertakings herein are given for the benefit of the Persons at my own free will without any inducement from any person and shall be relied on and are enforceable by the Persons, collectively or individually, and binding my child/ward, me, our heir, administrator, personal representatives and successors in title. 13. I agree to the information contained herein being made available to any person or body deemed appropriate by the Organizer. I understand that the Organizer relies on the information provided in this document which I confirm is accurate, complete and up to date. 14. I agree that all of the personal property of the campers shall be there at the camper's sole risk and that the Organizer shall not be liable for any damage to such personal property or loss suffered by campers in any manner whatsoever. I covenant and agree to hold the camp harmless from, and to indemnify and defend the camp against any and all loss, cost, damage, laibility, suit, claim, judgement and lien of every kind and nature that may occur or be claimed by, to or with respect, to any personal property caused by or resulting from Camper's usage or the camper's negligence; it shall be sole responsibility of the campers to protect his personal property, even if it is in lieu of appointing a third party to protect his personal property on their behalf I hereby certify that I have read and understand all the details and conditions of this form and are well aware of them. Signature of parent/guardian Date: Signature of camper Date:

5 How to make payment: Cheques should be made to White Water Summer Camp or you may make payment to our bank account and the bank-in slip to Our bank details are as follows: Name of Bank: Maybank Account No.: Swift code: MBBEMYKLPJY Note: A deposit of RM100, the receipt of this signed application form, and the signed Parent/Guardian Consent or Indemnity Form is required for registration. Date of payment received will be considered as the date of registration. However, even where the above conditions are met, the Organizer may, in its absolute discretion, reserves the right to accept or refuse an application.

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