National Workshop for Disability Inclusive Disaster Preparedness Registration Form Step 1 of 7 14% Reference numberNote: This registration is open to.. 1. Person with disability only 2. With or without OKU card 3. With or without caretaker/assistantI am...(Required) A person with disability Registered with JKM and have an OKU card Attending the event with a caretaker/assistant Personal Details of ParticipantFull name(Required)Phone number(Required)Email address(Required) Enter Email Confirm Email Gender(Required)Please choose an optionMaleFemalePrefer not to sayReligion(Required)Please choose an optionAgnosticAtheistBahá'í FaithBuddhismChristianityConfucianismHinduismIslamJainismJudaismShintoSikhismSpiritual but no religiousTaoism (Daoism)Traditional/Indigenous ReligionsZoroastrianismPrefer not to sayOther (please specify)Religion (others)(Required)Date of birth(Required)YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031Your date of birth selection is (waiting for selection)Nationality(Required)Please choose an optionAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsMalaysian identity card number(Required)Passport or other identity document number(Required)OKU card registration number(Required)Disability category based on classification in Malaysia(Required)Please choose an optionHearing ImpairmentVisual ImpairmentSpeech DisabilityPhysical DisabilityLearning DisabilityMental DisabilityMultiple Disabilities Personal Details of Caretaker/AssistantFull name(Required)Phone number(Required)Email address(Required) Enter Email Confirm Email Gender(Required)Please choose an optionMaleFemalePrefer not to sayReligion(Required)Please choose an optionAgnosticAtheistBahá'í FaithBuddhismChristianityConfucianismHinduismIslamJainismJudaismShintoSikhismSpiritual but no religiousTaoism (Daoism)Traditional/Indigenous ReligionsZoroastrianismPrefer not to sayOther (please specify)Religion (others)(Required)Date of birth(Required)YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031Your date of birth selection is (waiting for selection)Nationality(Required)Please choose an optionAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsMalaysian identity card number(Required)Passport or other identity document number(Required)Relationship to participant(Required)ParentGuardianSpouse / partnerSiblingChildRelativeFriendColleague / co-workerManager / supervisorDoctor / medical providerNeighbourCaregiver / support workerRoommate / housemateOther (please specify)Others (Relationship to participant)(Required) Event RelatedAre you currently attached with any organisation?(Required) Yes No Organisation name(Required)Position / Designation / Title(Required)Preferred short name of tag(Required)Preferred full name on certificate(Required) HealthDo you have any dietary restriction?(Required)Please choose an optionYesNo restrictionsDietary restrictions(Required)You may select more than one option as needed Vegetarian Vegan Pescatarian Halal Kosher Gluten-free Dairy-free / Lactose-free Nut-free No pork No Beef Low-carb / Keto Low-sugar / diabetic-friendly Organic-only Religious restrictions (please specify) Other (please specify) Others (dietary restrictions)(Required)Do you have any food allergies?(Required)Please choose an optionYesNo known allergiesFood Allergies(Required)You may select more than one option as needed Peanuts Tree nuts Shellfish Fish Eggs Milk/Dairy Wheat/Gluten Soy Sesame Corn Fruits (please specify) Other (please specify) Other (food allergies)(Required)Do you carry an EpiPen?(Required) Yes No Severity of allergy(Required)Please choose an optionMildModerateSevereAnaphylacticDo you have any accessibility needs or require any support to fully participate in the event?(Required)Please choose an optionYesNoAccess needs(Required)You may select more than one option as needed I use a wheelchair or mobility aid I am blind or have low vision I experience neurodivergence or cognitive disabilities I may need assistance with communication Other (please specify) Other (access needs)(Required)Do you require any of the following support during the event?(Required)You may select more than one option as needed No support needed Step-free access to the venue Reserved accessibility seating Sign language interpretation Priority assistance for registration/check-in Someone to assist or accompany me at the venue Other (please specify) Other (require support)(Required) Emergency ContactFull name(Required)Relationship(Required)Please choose an optionParentGuardianSpouse / partnerSiblingChildRelativeFriendColleague / co-workerManager / supervisorDoctor / medical providerNeighbourCaregiver / support workerRoommate / housemateOther (please specify)Other (relationship)(Required)Phone number(Required) Section BreakPlease confirm that the information below is correct and accurate before clicking submit. To go back and make changes, click the previous button below.{all_fields}Consent(Required) I hereby declare that the information provided is true, accurate and giving my permission to NWIDP to use it for anything needed for the overall event.
