Edaran Causeway Jamboree

BORANG RINGKASAN PENDAFTARAN 1ST JOHOR INTERNATIONAL CAUSEWAY JAMBOREE 2018 TARIKH : 2 - 5 OGOS 2018 MASA : K HAMIS, 2 OGOS (1.00 PETANG) - AHAD, 5 OGOS (5.00 PETA NG) KOLEJ RAHMAN PUTRA, PUTRA, UTM, JOHOR BAHRU, JOHOR, MALAYSIA NAMA NEGERI :

B IL

NAMA PEMIMPIN (GURU)

J ANTINA

NO K AD IC

NAMA SEK OL AH

NO TEL

CATATAN

1

KETUA

2

PENOLONG

3 4 5 6 7 8 9 10 11 12

B IL 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

NAMA PESERTA

J ANTINA

NO K AD IC

NAMA SEK OL AH

NO TEL

CATATAN (K ATEGORI)

FORM AG20143-1A.1

BORANG PERMOHONAN / APPLICATION FORM KATEGORI / CATEGORIES (Sila tandakan (X) / Please check (X)) Peserta (Participants (Participants)) :

Pengakap Kanak-Kanak

Pengakap Muda/Remaja

Pengakap Kelana

Pengakap Pen. Khas

Pemimpin (Scout (Scout Leaders) Leaders)

(A) BUTIRAN PERIBADI (Private Details) Nama/Name Nama/Name:: _________________________ ____________________________________ _______________________ _______________________ _____________________ __________  ________________________  _____________________________________ _________________________ _______________________ ____________________ _________ Jantina/Sex  Jantina/Sex :

Lelaki(Male Lelaki(Male))

Perempuan (Female) Female)

No. Kad Pengenalan (Identity Card No.)/ Passport No: __________________________ _____________________________________ ___________ Tarikh Lahir (Date (Date Of Birth): Birth): _____________________ _____________________ DD/MM/YY

Umur ( Age)  Age) : _______________________ _______________________

Kerakyatan: ______________________ _________________________________ ___________ Agama: ______________________ _____________________________ _______ Citizenship/Nationality Religion Kumpulan/ Daerah ___________________ ___________________ Group/ Troop/ District

Negeri/ Negara: ________________________ __________________________ __ State/ Country

No. Telefon (Rumah/Bimbit): __________________________ _________________________________ _______ Telephone (House/Mobile) ALAMAT SURAT MENYURAT (Correspondent (Correspondent Address) Address )  ________________________  _____________________________________ ________________________ _______________________ _______________________ ______________________ ___________  ________________________  _____________________________________ ________________________ _______________________ _______________________ ______________________ ___________  ________________________  _____________________________________ ________________________ _______________________ _______________________ ______________________ ___________ E-mel(E-mail  E-mel(E-mail ): ): ________________________ ____________________________________ ________________________ ______________________ ____________________ __________ Saya telah membaca kesemua peraturan dan syarat yang telah ditetapkan oleh Jawatankuasa Penganjuran 1ST JOHOR INTERNATIONAL CAUSEWAY JAMBOREE 2018 dan mengakui bahawa segala butiran yang dinyatakan di atas ini adalah benar. I have read all rules and regulations provided by the 1ST JOHOR INTERNATIONAL CAUSEWAY JAMBORE 2018 Committee and I confirm all the details given above is true. Tarikh /Date /Date:: ____________________ ____________________ Tandatangan: _____________________ ______________________________ _________ Signature /Name: Name: __________________________________________

…..2/

(B) BAHAGIAN PERAKUAN – Perlu Diisi oleh penjaga bagi peserta yang berumur di bawah 19 tahun (INDEMNITY SECTION - to be fill by guardians for participants under 19 years old) Saya memahami sepenuhnya bahawa saya TIDAK BERHAK untuk membuat sebarang tuntutan kepada pihak penganjur seandainya berlaku sebarang kemalangan ke atas saya/ anak jagaan saya semasa program 4 TH JOHOR INTERNATIONAL AGOONOREE 2018  ini berlangsung termasuklah ketika dalam perjalanan pergi dan balik ke kawasan program. I fully understand that I am NOT entitled to any claims towards the organizer if should there be any lost or injury sustained to me/my children during the duration of the 1ST JOHOR INTERNATIONAL CAUSEWAY  JAMBOREE 2018 program 2018 program in that will include during the the journey to and from the program. Tarikh /Date /Date ________________________ ______________________________ ______

Tandatangan Penjaga _______________________ _______________________ Parents/ Guardians Signature

Nama/Name Nama/Name   __________________________________________

(C) BAHAGIAN PENGESAHAN (Confirmation Section ) Saya mengesahkan dan menyokong permohonan ini, I confirmed and recommend this application, Tandatangan Pemimpin Pengakap & Cop Rasmi: _____ _________________________________ ________________________________________ _______ Scout Master’s Signature & Official Stamp TARIKH/ Date: Date: _____________________ _____________________

NAMA/ Name: Name: _________________________ __________________________________ _________

(D) BAHAGIAN KELULUSAN DELEGASI (Delegation Approval Section) Saya memperakui dan meluluskan permohonan ini. I recommend and approve this application. Tandatangan Pesuruhjaya Pengakap Negeri/ Daerah & Cop Rasmi: _______________________________ _______________________________ State/District Commissioner Signature & Official Stamp TARIKH/ Date: Date: ________________________ ________________________ NAMA/ Name: Name: __________________________ ___________________________________ _________

UNTUK KEGUNAAN SEKRETARIAT (FOR SECRETARIAT USE ONLY) NO RESIT (Receipt No) RM TUNAI TARIKH Tandatangan (Cash) (Date) (Signature)

CATATAN (Notes)