SAMPOERNA ACADEMY YEAR END CAMP SABTU, 15 16 December 2012

Kinasih Resort, Jl. Raya Sukabumi No. 17, Caringin - Bogor

FORMULIR PENDAFTARAN
Yang bertanda tangan di bawah ini: Nama Orang Tua : .. Nama Anak : Tanggal Lahir : Alamat : No. kontak : Dengan ini menyatakan setuju untuk mengisi formulir pendaftaran dan formulir kesehatan yang telah disediakan serta memberikan izin kepada (nama anak) untuk menjadi peserta Sampoerna Academy Year End Camp 2012. Saya mengetahui dan memahami tata tertib/persyaratan yang telah ditetapkan oleh Sampoerna Academy dan saya memberikan wewenang kepada penyelenggara untuk mengambil tindakan yang diperlukan demi kalancaran acara. Peserta membawa Rp 150,000 (seratus lima puluh ribu rupiah) dan diserahkan pada panita saat registrasi ulang (akan digunakan untuk kegiatan Community Service Giving Back to Society saat camp)

Transportasi yang akan peserta gunakan menuju lokasi Year End Camp: Diantar keluarga menggunakan kendaraan pribadi Shuttle bus yang disediakan panitia di Sampoerna Strategic Square - Jl. Jenderal Sudirman Kav. 45 Jakarta 12930

Tandatangan, Tanggal & Nama Jelas

Harap formulir ini dan health form (di bawah ini) segera diisi dan dikirimkan ke:

A-Z Communications [communicationsaz@gmail.com] CP: Rina 085782077555 Save file as: Daftar SA Camp (Nama peserta)

Terima kasih.

Sampoerna Academy Headquarter Sampoerna Strategic Square, North Tower, Lantai 27 Jl. Jenderal Sudirman Kav. 45 Jakarta 12930 Tel. (021) 577 2340 Fax. (021) 577 2341 | www.sampoernafoundation.org

PARTICIPANT HEALTH FORM Sampoerna Academy Year End Camp 2012

__________ SURNAME

__________ First

_________ Middle

____________ _______ Date of Birth F/ M

______ Blood group

Is the student on long term medication? Does the student take medication during school hours? Please list the name of the medication and the frequency

YES / NO YES / NO

Are there any known drug allergies? Please list the names of drug allergies:

Parents Name : _____________________________________________________________ Home address : _____________________________________________________________ Home Phone number : __________________________________ Office address : ______________________________________________________________ Office Phone number : __________________________________

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Sampoerna Academy Headquarter Sampoerna Strategic Square, North Tower, Lantai 27 Jl. Jenderal Sudirman Kav. 45 Jakarta 12930 Tel. (021) 577 2340 Fax. (021) 577 2341 | www.sampoernafoundation.org

HEALTH ADMISSION DETAILS :

Current Tuberculin Skin Test or X- Ray result within last twelve months. This is an annual recommendation. TB Skin test Result Date Chest X - Ray Result Date

Fill in : normal or not normal. If the result was not normal please explain:

BCG inoculation :

YES NO

date :

Does the student wear glasses or contact lenses? YES/NO Date of last vision test ___________________________ Date of last hearing test __________________________

IMMUNIZATIONS :

DATE OF LAST BOOSTER OR VACCINATION :

Diphtheria/Tetanus/whooping cough _________________ Tetanus (every 10 years) ____________________________ Typhoid injection (every 3 years) ______________________ Typhoid oral (every year) ____________________________ Mumps _________________________________________

Polio ____________________ Measles __________________ Rubella __________________ Others ___________________

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Sampoerna Academy Headquarter Sampoerna Strategic Square, North Tower, Lantai 27 Jl. Jenderal Sudirman Kav. 45 Jakarta 12930 Tel. (021) 577 2340 Fax. (021) 577 2341 | www.sampoernafoundation.org

These health conditions can be a concern. Please circle any that apply to your child.

Allergies, Asthma, Congenital anomalies, Convulsions/Epilepsy, Diabetes, Recurring ear infections, Hearing difficulties, Frequent headaches, Heart problems, Kidney/ Urinary infection, Menstrual problems, Orthopedics problems, Operation convalescence, Rheumatic fever, Skin problems, Tuberculosis, Visual problems, Others. Please comment on circled items:

_____________________________________________________________________________________ ___________________________________________________________ Explain any limitation on physical activity:

_____________________________________________________________________________________ _____________________________________________________

PERMISSION IS HEREBY GIVEN FOR EMERGENCY MEASURES TO BE INITIATED IN CASE OF ACCIDENT OR SUDDEN ILLNESS WITH THE UNDERSTANDING THAT I WILL BE NOTIFIED. I CERTIFY THAT ALL INFORMATION GIVEN ON THIS CARD IS COMPLETE AND CORRECT.

Signature of Parent : ________________________________date _____________________________

Please insure that the school is informed of any changes to the information on this documentation.

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Sampoerna Academy Headquarter Sampoerna Strategic Square, North Tower, Lantai 27 Jl. Jenderal Sudirman Kav. 45 Jakarta 12930 Tel. (021) 577 2340 Fax. (021) 577 2341 | www.sampoernafoundation.org