Membership Form

Name of Club / Society

: Leo Club of Heriot-Watt Metro

Year

: 2016

Personal Details
Full Name

: Click here to enter Full Name

Date of Birth

Date of Birth

Identity Card / Passport No

Passport No

: Click here to enter Identity Card /

HWUM ID NO

: Click here to enter HWUM ID No

Phone No (HP)

: Click here to enter Phone No (HP)

Email Address
Address@hw.ac.uk

: Click here to enter HWUM Email

Permanent Address
Address

: Click here to enter Permanent

Programme

Choose a Programme

School

Choose a School

Year / Semester

: Year

Choose a no

Semester

Choose a no

Existing Medical Condition (if any) : Choose - or enter any Existing

Medical Condition
Emergency Contact Name
Contact Name
Emergency Contact No

: Click here to enter Emergency

: Click here to enter Emergency Contact No

I
Click here to enter Full Name
(full name) acknowledge and
understand that participating in activities organised by clubs and societies
of the Heriot-Watt University Malaysia may carry a certain risk of physical
injury which may occur through no fault of any volunteer, participant,
employee or staff affiliated with the institution. I fully understand that
certain activity(s) may be strenuous and choose to participate completely
voluntarily and own accord. I accept full responsibility for my own safety. I
agree not to hold the institution or its management responsible for any
untoward incidents which may occur. Furthermore, I realize that it is my
responsibility to know my own limitations and will not act in a manner that
will bring harm and injurious to myself or others. I also agree to comply
with safety rules and regulations that are in place at the activity location.
It is also my duty to immediately point out any injuries or limitations that I
may have to the instructors at the activity location and to seek medical
attention. It is also my duty to report any safety issues / concerns to the

Student Support Services Department. I fully understand and agree to all

the above. The management reserves the right to terminate the
membership at any time of students who fail to comply with the
aforementioned.
(Signature)

Click here to enter Name

(Date)

Todays Date

(Signature of parent / guardian if under18)

Parent / Guardian Name
.

Click here to enter