youtex japan confirmation form
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7/25/2019 Youtex Japan Confirmation Form
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EVENT CONFIRMATION
FORM*All information provided is correct at time of confirmation
All fields below are required for registration of this event. Your personal data will be collected and used for the event as mention ed above.
PERSONAL PARTICULARS
EMERGENCY CONTACT PERSON (YOUTEX will contact this person in the event of an emergency)
By f i lling up the information below, you declare that you have obtained consent from your emergency contact for YOUTEX to
col lect, use, a nd disclose his/her personal data in case of emergency.
Event Name : Youth Excursion 2016, Tokyo - Japan Program
Date : 17th- 22
ndSeptember 2016 Venue: Tokyo, Japan
Regis tration Fee : IDR 12.000.000 (lates t by 30thJune 2016)
Date of Confirmation :
Full Name :
Gender : Male/Female (circle where appropriate) Date of Birth : / /
Email :
Contact No : (HP):
Addres s :
Passport No :
Nationality :
University / Institution :
Facebook/Twitter :
T-Shirt Size : S/M/L/XL/XXL (circle where appropriate)
Special Dietary : None/Halal/Vegetarian/Others (circle where appropriate)
If others, please specify:
Any Medical Condition : Yes / No (circle where appropriate)
If others, please specify:
Name : Relationship :
Contact No :
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7/25/2019 Youtex Japan Confirmation Form
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EVENT CONFIRMATION
FORM*All information provided are correct at time of confirmation
Terms & ConditionsParticipants must also prove that their are physically able to take the YOUTEX Program and/or are in good
health. Therefore, please find out doctor or medical specialist is authorised to issue you with the Health
Certificate.
Participants wil l have to indicate their medica l his tory/conditions in the field above. Each indi vidual wil l have
to take personal responsibility to their own health condition.
YOUTEX reserves the right to change the content of the event with or without pri or notice.
Due to l imited places available, only registrations with full payment / complete information made are deemed
as confirmed on a firs t come first served bas is .
All registered participants for this event wil l be contacted via email or telephone for further confirmation of
their particula rs.
Inthe case of any disputes during the event whenever appl icable, the decis ion made by the organizer is fi nal .
Registration fee is non-refundable.
Personal Data
Bysigning below, you consent to the collection, use and/or disclosure of your personal particulars by
YOUTEX for the purposes of organizing this event, and/ or uses by YOUTEX for analysis and research
purposes pertaining only to matters in relation to such events/ programs.
Please update YOUTEX [email protected] any changes in contact detai ls so as to facili tate communication
I shal l not hold the organizer responsible for any damage or loss of property, injury or l oss of l ife which may be sustained
by me during the activity arisi ng from any cause in connection with the event.
Signature :
Full Name :
Date :
*please print this confirmation letter and give the original signaturePlease email this file saved as your name and also attach Health Certificate to email: [email protected]
latest by 30th
June 2016.
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