“SSEAYP International: SSEAYP together Experience Culture”
1 2 3 4 5 Name (As shown in passport) Nationality Passport Details (Please attach your passport copy) Gender Date of Birth (dd/mm/yyyy) First Name: Last Name: Passport Number: Expiry Date: Type: ☐Ordinary ☐ Official ☐Female ☐ Male Age ☐Ex-PY of SSEAYP (Year:) ☐Ex-NL of SSEAYP (Year:) ☐Ex-Facilitator of SSEAYP (Year:) ☐Spouse of Ex- PY /NL/ Facilitator of SSEAYP (Name:) ☐Family of SSEAYP (Name:) ☐Host Family of SSEAYP ☐Ex-PY of INDEX (Year:) ☐Ex-PY of SVVY (Year:) ☐Friends of Ex-PY ☐ Member ☐ Board Members, position: ___________________ ☐ Other: ___________________________ Address: Phone: Mobile: Email: Name of Office / School: Office / School 10 (Please add country code to Phone / Mobile ) Position: Address: Tel: Mobile: Email: ☐ Yes, Please specify: ☐ No ☐ Yes, Please specify: ☐ No years old
Position in Alumni Association Residential address and Contact Details (Please add country code to Phone / Mobile ) Occupation
11 Religion 12 Food Restrictions/ Allergies
13 Prescription Drugs
Name: Emergency Contact 14 (Please add country code to Phone / Mobile ) Relationship to you: Phone: Mobile: Email:
Arrival Arrival date: Arriving Laos by: ☐ Wattay International Airport, Flight Number: ☐ Lao-Thai Friendship Bridge: Accommodation Name: , Contact : Departure date: Departure from Laos by: ☐Wattay International Airport, Flight Number: ☐ Lao-Thai Friendship Bridge: Arrival time: : hrs
If you arrive in Laos earlier please provide your accommodation before SIGA
Departure Late Departure
If you willing to extend your stay in Laos, please provide your accommodation after SIGA
Accommodation Name: , Contact:
Those who arrive earlier or extend their stay should arrange their transportation between the nearest airport/station and the avenue on their own.
☐Twin/ Triple Sharing Room ☐Single Occupancy Room 1 Type ☐Children (4-11 years old) ☐Children (0-3 years old needing their own bed) Roommate Preferred (Not Guarantee) ☐Children (0-3 years old needing no extra bed) Name: Country: USD 250 USD 330 USD 150 USD 150 0
☐I will join Pre-SIGA Social Contribution Activity (April 22-24) Pre-SIGA Social (Participation Fee: USD 95) 3 Contribution Activity (SCA) ☐I will Not join Pre-SIGA Social Contribution Activity ! CANCELLATION POLICY ! Before March 18th, 2013: No Charge th From March 19 – 25th , 2013: Half participation Fee th On or after March 25 , 2013: Full Participation Fee EXPENSES PERTAINING TO ACCIDENTS, ETC
SIGA Organizing Committee will not be liable for expenses for medical treatment. Each person shall be responsible for arranging his/her own travel, medical and accident insurance, etc.
-Traditional Culture: Arms Giving Participation Fee: USD 5
(This activity will conduct on 26 April 2013, at 5:00 am)
☐ Yes, I will join Alms Giving ☐ No. Thanks
If you are interested to extend your stay after SIGA, please see tour programs detail on our website www.siga2013.com in after SIGA menu.
All participants are required to register and make payment to your Alumni Association (AA) in your respective country on or before March 18, 2013, 05:00 pm Laos time. I hereby verify that all information filled in this registration is accurate and acknowledge that I have received and agreed to the terms and conditions set out in the registration form. Name of Participant: Signature For more information and query please contact SIGA 2013 Organizing Committee Tel: +856 21 454 153, +856 21 416 272; Fax: +856 21 454 153, +856 21 416 272 Email: firstname.lastname@example.org; Website: www.siga2013.com Date of submission:
FOR SSEAYP ALUMNI ASSOCIATION USE ONLY: