DUKE OF EDINBURGH’S INTERNATIONAL AWARD

PARTICIPANT REGISTRATION FORM

Please print clearly in CAPITALS or type your details in. You must complete all of the questions.

Award Site (School / College / University / Vocational/ Skill Institution) Award Leader:

Name :

Personal details:

First name: Last name:

IC / Passport Number: Age :

Gender: Male Female Date of Birth:

Primary language: Bahasa / English / Mandarin / Tamil / Others

Skills:
Date you wish to start your Award program if known
(enrollment date): Physical Recreation:
Community Service:
Exploration & Expedition :
Award level:

Select your entry Award Level: Bronze Silver Gold

Have you registered for any previous levels of the Award? No Yes

When you first sign in to Online Record Book (ORB) you will be asked to record some personal details such as your
contact details, ethnicity and personal circumstances along with details of any medical needs you may have. This data
is used to enable your Leaders to support you doing your Award program and for the Award’s statistical and reporting
purposes. You will always have a ‘prefer not to say’ option.

Contact details:
Address (line1):
Email address:

Address (line 2):

Town/City:

Postcode:
State:

Mobile number:
Home Phone:
 DUKE OF EDINBURGH’S INTERNATIONAL AWARD
PARTICIPANT REGISTRATION FORM
Emergency contact details:

Emergency Contact name: Relationship to you:

Emergency contact telephone number(s):

Declaration:
“As a participant The Duke Of Edinburgh’s International Award would like to promise that I will give my full
commitment in my efforts to achieve the objectives which set out in philosophy of “The Duke Of Edinburgh’s
International Award ”. I understand that this participation is voluntary basis for personal development, family,
Community and my nation”

Participants Name Date Signature

Consent to Enroll from Parent or Guardian (if applicant is under 18 years old):
"I agree to authorize and support my son / daughter to participate in the “The Duke Of Edinburgh’s International
Award ” related activities. I will ensure my son / daughter will follow all the conditions set by the Award Authority
this program”. I note that it is my responsibility to check that any activity my son / daughter undertakes for their
Award program is appropriately managed and insured, unless the activity is directly managed or organized by their
Award Site.

Parents / Guardian name IC / Passport Number Mobile Number Address Signature

Photography/Video Release Consent (if applicant is under 18 years old):

I grant The Duke of Edinburgh’s International Award Malaysia (DOE Malaysia) the right to take or use
photographs/video of me and my property in connection with completing my DOE Award. I authorize the DOE
Malaysia the right to use and publish these photos/video in print and/or electronically with or without my name,
for any lawful purpose, including publicity, illustration, adverting, and Web content. I have read and understand
the above:
Parents / Guardian name Date Signature

For Office Use :

Received Date :
This Application Form :

Approved / Not Approved

Signature & Award Unit Stamp