EmailMe Form - POPX Registration Form (SPECIAL)

DISCOUNT CODE : SPCL40
Swimmer's Personal Information
Name *
First Last
Email *
Mobile Number *
Country Code + Mobile No
For e.g 60102345678
Date of birth *
DD / MM / YYYY
Gender *
Age Category *
7 - 11
12 - 19
20 - 40
41 - 75
Age is as of on 1/1/2020
Nationality *
Personal Document *
Passport
Malaysian National Registration Identity Card (MNRIC)
Passport/ MNRIC No *
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
In case of accident contact *

Name

Mobile Phone No.

Country Code + Mobile No
For e.g 60102345678
Parent/Guardian *

Name

Relation (Father/Mother/Other: please state)
Previous OWS participant? *
Yes
No
Year of Last participation *
Name of Club (if any)
T-Shirt, Swim Bouy & Group Personal Accident
POPX T-Shirt
Adults T-Shirt Measurement
Kids T-Shirt Measurement
T-Shirt SIZE *
For Safety reasons, swiming buoy is mandatory to ALL participants of POPX. You can bring your own buoy
Would you like to buy a security swim bouy? *
Yes
No
The price is MYR65 / USD15.70
Would you like to have Group Personal Accident (1 day)? *
Yes
No
MYR25,000/USD6000 for Death and Permanent disablement
MYR2000/USD480 for Medical Expenses

Premium is MYR15 / USD3.60 (including SST and stamp duty)

Group Personal Accident is provided by MSIG Insurance (M) Bhd.
Disability Condition
Type Of Disability *
Limbs
Vision
Speech
Hearing
Special Need (e.g ADHD, Autism etc)
Doctor's Endorsement Letter *
Questions / Comments
NEXT : Choose Your Swim Distance

Name
Mobile Phone No.

Name
Relation (Father/Mother/Other: please state)