NATIONAL YOUTH DAY 2015 November 11-15, Archdiocese of Tuguegarao

EPISCOPAL COMMISSION ON YOUTH - CATHOLIC BISHOPS’ CONFERENCE OF THE PHILIPPINES

Blessed are the pure in heart, for they shall see God. [Mt 5:8]

INDIVIDUAL REGISTRATION FORM

Origin (write the name of your diocese/ organization)

A. PERSONAL DETAILS

Fr. Sr. Ms.

Br. Mr.

Title Last Name First Name Nickname

DD MM YYYY House Number / Street / Barangay or District / Province

Birthdate Residential Address (Current)

Email Address Mobile Phone Number

B. CONTACT PERSON IN CASE OF EMERGENCY

Full Name Relationship to You Contact Number

C. HEALTH DECLARATION

This Health Declaration will help the NYD2015 Organizers understand the health conditions of a NYD2015 participant so as to provide timely support and to make necessary arrangements in the event of an emergency. Please provide accurate data.

C.1. Allergy: Have you ever suffered from any allergy (e.g. medicine, food, etc.) YES NO If yes, provide details: ____________________________________________________________________

C.2. Are you on regular medication? YES NO If yes, provide details on the medicine/s: _____________________________________________________

C.3. Do you have a special diet (e.g. vegetarian, meat, fish, less salt, etc.)? YES NO If yes, provide details: ____________________________________________________________________

C.4. Will you require mobility assistance? YES NO If yes, provide details: ____________________________________________________________________

IMPORTANT: If you checked YES to C.1. and/or C.2., the NYD2015 Organizers require that you seek your doctor’s advice before joining and that you submit documentary proofs, e.g. doctor’s certification/ medical allergy card/ etc., with this form.

D. AUTHORIZATION AND WAIVER

I confirm that all information herein are correct and accurate to the best of my knowledge and I authorize the NYD2015 Organizers to use with discretion the information contained herein as the NYD2015 Organizers deem necessary in view of my participation to the NYD2015. I also understand that the NYD2015 Organizers will not be held liable for any untoward incident that may occur to me during the event. I hereby attach my signature below to vouch for the veracity of the above statements.

This portion must be signed by the participant accomplishing this form. If the participant is a minor (17 or below), then this must be signed by any of his/her parents or legal guardian.

Full Name Signature Date Accomplished

ARCHDIOCESE OF LIPA

MAGSINO MARY YE YEYE

24 09 1995 #86 BRGY. BAYORBOR, MATAASNAKAHOY, BATANGAS

maryyemagsino@yahoo.com.ph 09363854716

ROEL D. MAGSINO FATHER 09175029165

NO EGGS

MARY YE A. MAGSINO JULY 24, 2015