LAMPIRAN

WELCOME DELEGATES!

SELAMAT ANDA TERPILIH MENJADI DELEGASI

YOUTH CHANGEMAKER VOLUNTEERING BATCH III, MALAYSIA !

Sebagai tahap lanjut, berikut kami kirimkan LoA (Letter of Acceptance) dan
Indemnity Form. LoA adalah surat resmi yang menyatakan bahwa saudara/i
telah resmi menjadi delegasi Youte Batch III dan Indemnity Form adalah formulir
pernyataan bahwa saudara/i siap menjadi delegasi serta pernyataan panitia
bahwa kami siap untuk bertanggung jawab terhadap delegasi.

Salam Hangat,
Tim Youth Changemaker Volunteering Batch III
2022
 INDEMNITY FORM

Please sign and scan this form, then send back to the committee
I Wahyudi, hereby declare that I am participating in Youth Changemaker Volunteering Batch
III, Malaysia August 23th – 26th 2022, with my own free will and volition, having understood the
risk involved in the above mentioned activity. I shall not hold the organizers of the above
mentioned activity, namely the Changemaker Indonesia responsible in any way for my
death, injury or disability or any loss or damage whatsoever arising from any cause in
connection with the activity or my participation there in.

Kubu Raya, July 25, 2022

Wahyudi

Parental consent for participant/delegates below 18 years old.

I ____________________, hereby allow my son/child/ward to participate in the above
activity, having understood the risks involved in the above mentioned activity. I understand
and agree that I will have no claim whatsoever against the organizers the Changemaker
Indonesia injury or any loss or any kind including loss of life that my son/child/ward may
sustain during the whole period of the above mentioned activity.

________________, August ____ 2022

signature

( ___________________ )
Full Name Parents/Guardian

Contact information in emergency case

Name : Dewi Sartika
Email : dewisartika2426@yahoo.com
Mobile No. : +6289693510018
Relation : Sister
 WELCOME DELEGATES!

SELAMAT ANDA TERPILIH MENJADI DELEGASI PARTIAL FUNDED

YOUTH CHANGEMAKER VOLUNTEERING BATCH III, MALAYSIA !

Sebagai tahap lanjut, berikut kami kirimkan LoA (Letter of Acceptance) dan
Indemnity Form. LoA adalah surat resmi yang menyatakan bahwa saudara/i
telah resmi menjadi delegasi Youte Batch III dan Indemnity Form adalah formulir
pernyataan bahwa saudara/i siap menjadi delegasi serta pernyataan panitia
bahwa kami siap untuk bertanggung jawab terhadap delegasi. Sebagai bentuk
komitmen awal, silakan kirim kembali “INDEMNITY FORM” Paling lambat 22
Juli 2022 pukul 23:59 WIB.

Salam Hangat,
Tim Youth Changemaker Volunteering Batch III
2022
 INDEMNITY FORM

Please sign and scan this form, then send back to the committee
I Wahyudi, hereby declare that I am participating in Youth Changemaker Volunteering Batch
III, Malaysia August 23th – 26th 2022, with my own free will and volition, having understood the
risk involved in the above mentioned activity. I shall not hold the organizers of the above
mentioned activity, namely the Changemaker Indonesia responsible in any way for my
death, injury or disability or any loss or damage whatsoever arising from any cause in
connection with the activity or my participation there in.

Kubu Raya, July 21, 2022

Wahyudi

Parental consent for participant/delegates below 18 years old.

I ____________________, hereby allow my son/child/ward to participate in the above
activity, having understood the risks involved in the above mentioned activity. I understand
and agree that I will have no claim whatsoever against the organizers the Changemaker
Indonesia injury or any loss or any kind including loss of life that my son/child/ward may
sustain during the whole period of the above mentioned activity.

________________, August ____ 2022

signature

( ___________________ )
Full Name Parents/Guardian

Contact information in emergency case

Name : Dewi Sartika
Email : dewisartika2426@yahoo.com
Mobile No. : +6289693510018
Relation : Sister
 WELCOME DELEGATES!

SELAMAT ANDA TERPILIH MENJADI DELEGASI PARTIAL FUNDED

YOUTH CHANGEMAKER VOLUNTEERING BATCH III, MALAYSIA !

Sebagai tahap lanjut, berikut kami kirimkan LoA (Letter of Acceptance) dan
Indemnity Form. LoA adalah surat resmi yang menyatakan bahwa saudara/i
telah resmi menjadi delegasi Youte Batch III dan Indemnity Form adalah formulir
pernyataan bahwa saudara/i siap menjadi delegasi serta pernyataan panitia
bahwa kami siap untuk bertanggung jawab terhadap delegasi. Sebagai bentuk
komitmen awal, silakan kirim kembali “INDEMNITY FORM” Paling lambat 22
Juli 2022 pukul 23:59 WIB.

Salam Hangat,
Tim Youth Changemaker Volunteering Batch III
2022
 INDEMNITY FORM

Please sign and scan this form, then send back to the committee
I Wahyudi, hereby declare that I am participating in Youth Changemaker Volunteering Batch
III, Malaysia August 23th – 26th 2022, with my own free will and volition, having understood the
risk involved in the above mentioned activity. I shall not hold the organizers of the above
mentioned activity, namely the Changemaker Indonesia responsible in any way for my
death, injury or disability or any loss or damage whatsoever arising from any cause in
connection with the activity or my participation there in.

Kubu Raya, July 21, 2022

Wahyudi

Parental consent for participant/delegates below 18 years old.

I ____________________, hereby allow my son/child/ward to participate in the above
activity, having understood the risks involved in the above mentioned activity. I understand
and agree that I will have no claim whatsoever against the organizers the Changemaker
Indonesia injury or any loss or any kind including loss of life that my son/child/ward may
sustain during the whole period of the above mentioned activity.

________________, August ____ 2022

signature

( ___________________ )
Full Name Parents/Guardian

Contact information in emergency case

Name : Dewi Sartika
Email : dewisartika2426@yahoo.com
Mobile No. : +6289693510018
Relation : Sister
 WELCOME DELEGATES!

SELAMAT ANDA TERPILIH MENJADI DELEGASI PARTIAL FUNDED

YOUTH CHANGEMAKER VOLUNTEERING BATCH III, MALAYSIA !

Sebagai tahap lanjut, berikut kami kirimkan LoA (Letter of Acceptance) dan
Indemnity Form. LoA adalah surat resmi yang menyatakan bahwa saudara/i
telah resmi menjadi delegasi Youte Batch III dan Indemnity Form adalah formulir
pernyataan bahwa saudara/i siap menjadi delegasi serta pernyataan panitia
bahwa kami siap untuk bertanggung jawab terhadap delegasi. Sebagai bentuk
komitmen awal, silakan kirim kembali “INDEMNITY FORM” Paling lambat 22
Juli 2022 pukul 23:59 WIB.

Salam Hangat,
Tim Youth Changemaker Volunteering Batch III
2022
 INDEMNITY FORM

Please sign and scan this form, then send back to the committee
I Wahyudi, hereby declare that I am participating in Youth Changemaker Volunteering Batch
III, Malaysia August 23th – 26th 2022, with my own free will and volition, having understood the
risk involved in the above mentioned activity. I shall not hold the organizers of the above
mentioned activity, namely the Changemaker Indonesia responsible in any way for my
death, injury or disability or any loss or damage whatsoever arising from any cause in
connection with the activity or my participation there in.

Pontianak, July 21, 2022

Wahyudi

Parental consent for participant/delegates below 18 years old.

I ____________________, hereby allow my son/child/ward to participate in the above
activity, having understood the risks involved in the above mentioned activity. I understand
and agree that I will have no claim whatsoever against the organizers the Changemaker
Indonesia injury or any loss or any kind including loss of life that my son/child/ward may
sustain during the whole period of the above mentioned activity.

________________, August ____ 2022

signature

( ___________________ )
Full Name Parents/Guardian

Contact information in emergency case

Name : Dewi Sartika
Email : dewisartika2426@yahoo.com
Mobile No. : +6289693510018
Relation : Sister
 WELCOME DELEGATES!

SELAMAT ANDA TERPILIH MENJADI DELEGASI PARTIAL FUNDED

YOUTH CHANGEMAKER VOLUNTEERING BATCH III, MALAYSIA !

Sebagai tahap lanjut, berikut kami kirimkan LoA (Letter of Acceptance) dan
Indemnity Form. LoA adalah surat resmi yang menyatakan bahwa saudara/i
telah resmi menjadi delegasi Youte Batch III dan Indemnity Form adalah formulir
pernyataan bahwa saudara/i siap menjadi delegasi serta pernyataan panitia
bahwa kami siap untuk bertanggung jawab terhadap delegasi. Sebagai bentuk
komitmen awal, silakan kirim kembali “INDEMNITY FORM” Paling lambat 22
Juli 2022 pukul 23:59 WIB.

Salam Hangat,
Tim Youth Changemaker Volunteering Batch III
2022
 INDEMNITY FORM

Please sign and scan this form, then send back to the committee
I Wahyudi, hereby declare that I am participating in Youth Changemaker Volunteering Batch
III, Malaysia August 23th – 26th 2022, with my own free will and volition, having understood the
risk involved in the above mentioned activity. I shall not hold the organizers of the above
mentioned activity, namely the Changemaker Indonesia responsible in any way for my
death, injury or disability or any loss or damage whatsoever arising from any cause in
connection with the activity or my participation there in.

Pontianak, July 21, 2022

Wahyudi

Parental consent for participant/delegates below 18 years old.

I ____________________, hereby allow my son/child/ward to participate in the above
activity, having understood the risks involved in the above mentioned activity. I understand
and agree that I will have no claim whatsoever against the organizers the Changemaker
Indonesia injury or any loss or any kind including loss of life that my son/child/ward may
sustain during the whole period of the above mentioned activity.

________________, August ____ 2022

signature

( ___________________ )
Full Name Parents/Guardian

Contact information in emergency case

Name : Dewi Sartika
Email : dewisartika2426@yahoo.com
Mobile No. : +6289693510018
Relation : Sister