1. Name (in full & block)

2. I/C No. / Passport No.

3. Sex M F 4. Date of Birth

5. Address

6. Telephone No.

7. 9. T.Shirt Size M L XL

8. Others / Company ___________________________

NEXT STEPI, the abovenamed hereby enclose RM ………………………………(cash only) as my entry fee & agree to abide by the conditions & rules of the walk, I certify that the details given above are correct & I am physically fit & sufficiently trained to finish the Walk. I will attempt to complete the Walk within the limit.

Athlete's Waiver/Indemnity : In consideration of the Organiser accepting this entry, I upon entry & registration to participate in the above Walkathon, hereby for myself, my heirs, executors & administrators, waive & release any & all rights or damages I may haveagainst the Organisers holding this walkathon, their representatives, asignees, sponsors & co-sponsors for all injuries, death & invalidityI may sustain during the course of the event or arising as a result of it. I hereby indemnify & keep you indemnified & waived against all claims or damages that may arise in consequence of the above.

…………………………………………….. …………………………………………………………..

For Participants Under 18 Years Of AgeI parent/guardian of the participant, whose particulars appear above, confirm, that I fully understand & appreciate the effect of the above waiver & hereby agree & declare on behalf of the participant that the purport of the Waiver Clause will have equal binding effect on the participant.

I hereby consent to his/her participation in the above walkathon.

Name: ………………………………………………………………………………………………………………………I/C No. …………………………………………………………………………………

Date: …………………………………………. ………………………………………………………….. Signature of Parent / Guardian

RULES, REGULATIONS & PAYMENT RECEIPT

This walk is open to staff of LohGuanLye SPECIALISTS CENTRE (LSC), their family members and the general public.

Entry Forms can be downloaded from www.lohguanlye.com and also available at LSC Reception Counter,

Main Wing (B3, Macalister Road). Closing date for registration is 14 September 2013. Late entries will not be entertained.

The registration fee is RM 20.00 per pax (Includes T-shirt & Goodie Bag).

Please collect your T-shirt at LSC Reception Counter (B3, Main Wing) between 19 to 20 September 2013 (10am to 4pm)

or 21 September 2013 (10am to 1pm).

Participants are to assemble at the LohGuanLye SPECIALISTS CENTRE (B3, Main Wing). The reporting time is 6am sharp.

The Management of LohGuanLye SPECIALISTS CENTRE wish to thank everyone for their valued participation in making this

World Heart Day Walkathon a success.

Payment received on:……………………………… Received by:……………………………………….

WORLD HEART DAY WALKATHON 29 SEPTEMBER 2013 (SUNDAY)

REGISTRATION FORM

Date Participant's Signature

Day Month Year

Staff / Department ___________________________