Escolar Documentos
Profissional Documentos
Cultura Documentos
ANNEX B
All information provided will be kept strictly confidential and use only for YMAC
Nationality Singapore Citizen Singapore PR thers! pls specify " ######################## Race Age
S &&(
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NR+C No
-ear
-ear
)ietary Re1uirements
Address (only if the address is different from a3o4e) Contact Payment Home $el Che1ue No" HP *an5" ff $el
'edical )eclaration .) Ha4e you e4er had chest pain high 3lood pressure heart pro3lems asthma 3ronchitis tu3erculosis fits epilepsy fainting attac5s se4ere head in6ury ear pro3lems7deafness ner4ous illness dia3etes a carrier status for any infectious disease medical treatment for a3o4e 8ithin last / years! if yes! please specify ############################ /) )o you re1uire routine medication currently9 No 0) )o you ha4e a: any disa3ilities or chronic medical ailment 8hich may affect your participation for this conference No -es! please specify ############################################ -es! please specify ############################################
3: any other medical information7allergies to note for this conference No -es! please specify ############################################
Declaration I declare that I am currently not suffering from any acute ailments or diseases. I shall comply fully with the conditions and regulations laid down by the YMAC Organizers 2013. I confirm that I have read and fully understood all the Parts in this registrationformandthat all the informationprovidedhereinis true.
Name of Participant
Signature
Date