PARTICIPATION FORM WALK THE TALK – MEN ON BOARD TO STOP VIOLENCE AGAINST WOMEN NAME NIRC OR PASSPORT CONTACT NUMBER EMAIL ADDRESS TSHIRT SIZE –
PARTICIPATION –
All registered walkers will be entitled to a t-shirt and goody bag.
The Talk is open on a “first come first served” basis
S - C 38”
XL – C 44”
M – C 40”
XXL – C 46”
L – C 42”
XXXL – C 48”
WALK ONLY
RM30.00
WALK AND TALK on
RM40.00
“Men on Board-Walk the Talk Violence Against Women”
for the first 500 registered participants. Refreshments will be served after the Talk.
EMERGENCY CONTACT PERSON EMERGENCY CONTACT PERSON’s TELEPHONE NO
Payment Method : Payment can be made by cash or crossed cheque to: SOROPTIMIST INTERNATIONAL REGION OF MALAYSIA – SPECIAL PROJECT Public Bank account no: 317 9055 314 Email completed Entry Forms with the bank deposit slip to : siromwtt@gmail.com Direct all enquiries to : Nora Lam – 0127182273 - nora@nswlam.com / Joyce Kee – 0126593814 – joyce@westports.com.my / Helena Cheah – 0122121361 – cheahhelena@yahoo.com DISCLAIMER: I, hereby declare that I am entering the SIROM Walk The Talk 2014 at my own risk and shall not hold The Organizer, its agencies and sponsors responsible for any incident, injury, death, loss of property cause before, during and after the event. I certify that all the above particulars given are correct.
SIGNATURE:
DATE: