REGISTRATION FORM Name Last name First name Nickname

REGISTRATION FORM Name : ____________________ Last name First name Nickname : ______ M. I. Age : ___ Birthday : _ _/_ _ Sex : ___ Civil Status : ___ Nationality : _____ Home Address : _______________________________ Home Phone No. : ____________ Mobile No. : ____________ Occupation : ____________ Business/school: ____________ Business//school address : ___________________________ Business Phone no. : _____________ Fax No. : ___________ Email Address : ______________ Club Affiliation : _______________ Position : ___________ In case of emergency: Contact person : _______________ Relation : ___________ Address : _____________________ Phone No. : _______ WAIVER I, _________________, of legal age and a resident of ___________________________, hereby hold Philippine Airlines Mountaineering Club (PALMC) and/or any of their authorized representative or agents free and harmless from and against any and all lawsuits, losses, damages or liabilities of whatever kind and nature arising from my participation in the 25 th MFPI Congress. I understood and accepted the fact that the activities in the 25 TH MFPI CONGRESS have inherent danger and risks; that I was properly oriented on the terms and conditions on my participation on the said event and I am taking full responsibility and willingly accept without prejudice to the PALMC and/or any of their authorized representative all the risks and dangers involved out of my said participation. This is also to certify that all information I have given here are true and correct. _________________ Affiant signature over printed name Date __________________________ (SECRETARIAT USE) Date paid : _________ O. R. No. : ________ Mode : ______________________ Authorized Representative Signature