Date of Event / 3rd March 2018 (Saturday)
Location / Methodist College Kuala Lumpur
Closing Date: By 5.00 PM, 23rd February 2018 or when registration reaches capacity prior.
Registration Fee: RM 30/- applies per person.
STUDENT DETAILS - As they appear on Passport – PLEASE WRITE IN CAPITAL LETTERS
Family Name / First Name / M / F
Preferred / Date of Birth / Age
NRIC No. / Email
Mobile No. / Phone No.
Address
PARENT/GUARDIAN CONTACT INFORMATION - PLEASE WRITE IN CAPITAL LETTERS
Family Name (1) / First Name / M / F
Mobile No. / Relationship
Family Name (2) / First Name / M / F
Mobile No. / Relationship
ACADEMIC DETAILS
School Name / Year Level
Address
HOW DID YOU FIND OUT ABOUT THIS PROGRAM?
School / Family / Fair
Friend / Exhibition / Other
Agent (If Yes, Which One?)
MEDICAL INFORMATION
Please note that if you have a condition that requires medication, it is your responsibility to bring sufficient supplies. Treatment/Medication for condition (dosage etc.):
DIETARY REQUIREMENTS: Please (X) whichever applicable
Halal / Vegetarian / Lactose Free
No Beef / Vegan / I have NO Dietary Requirements
Peanut Allergy / Gluten Free
Others (Please provide information)
Refund Policy:
Applications who registers for a place at the Medical Careers Day and subsequently decide to withdraw must notify Penang Medical College in writing. No refund will be made if notification of withdrawal is received less than seven days or less before event commencement.
If you are not able to attend, but would like to delegate your friend to replace your seat, you are required to inform Penang Medical College on the name change.
Declaration:
▪ / I authorise Penang Medical College/Methodist College Kuala Lumpur to commmunicate with my parents or guardian any information in relation to my participation in the Medical Careers Day;
▪ / If a third party is involved in the event, I understand and accept that Penang Medical College may provide information about myself to them;
▪ / Should I require medical attention, I authorise Penang Medical College to take appropriate action within th College;
▪ / Where I have an existing condition (such as medical, psychological or physical condition or disabilty) for which I may require additional support from Penang Medical College or Methodist College Kuala Lumpur during the event, I will advise Penang Medical College before commencing the program;
▪ / I understand and accept that the Penang Medical College policies may change from time to time and I accept that it is my responsibility to keep up to date with these changes;
▪ / In registering for this event, I certify that the information that I have provided is true and correct.
Signatures
Student's Signature / Parent/Guardian's Signature
Student's Name / Parent's Name
Date
Disclaimer:
1) Upon completion of this registration form, kindly scan the signed forms to:
- Miss Cheah Jo San ()
2) Payment can be made to our collaborating partner's bank details as below.
Account Name / Penang Medical College Sdn Bhd
Bank Name
Branch / CIMB Islamic Bank Berhad
409, Jalan Burmah, 10350, Penang
Account No. / 8602 154 353
Swift Code / CTBBMYKL
3) PMC has the right to deny access to students who have not got the parent/guardian's consent above.
4) For bulk registration by school counsellors, please refer to the additional form for bulk registration.
5) Payment can be done after confirmation of registration by the organizer. You will be informed by email on payment details. If you have any queries please do not hesitate to contact the organizer via .
6) Please send in a copy of the slip after making the payment to the email above.
In collaboration with: