Membership Form 2022

1
Please submit membership fee to bank account below:

Parents and Community Empowerment
United Overseas Bank (Malaysia) Bhd (UOB)
256-305-173-8

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2
Are you a new member?
YESNO
3
Type of Membership* This field is required.
Ordinary (individual)
Affiliate (individual without Breakthru Cert, or not staying in KL or Selangor)
Ordinary / Associate Lifetime Membership
Associate (company or organization)
Honorary Membership (recommended by committee)
4
Name (as per IC)* This field is required.
First Name
Last Name
5
Gender
Male
Female
6
Nationality
Malaysia
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
7
Date of Birth* This field is required.
Date
Day
Month
Year
8
MyKad / IC / Passport* This field is required.
9
Residential Address
Street Address
Street Address Line 2
City
State
Zip Code
Malaysia
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Email* This field is required.
example@example.com
11
Phone Number
Please enter a valid phone number.
12
Occupation
13
Number of Childrenincluding typical child
14
Maritial Status
Married
Single
Separated
Widowed
Divorced
15
Reason for joining
16
Willing to serve as
Committee
Volunteer
Subcommitee
KL Area
Kajang Area
17
Course(s) You Attendeded(for Ordinary Members only. If you do not have attended any BG, MBL, RMT, TFH or 3PLAY courses you may apply as an Associate member)
Course Name
Date Taken
Instructor
Course 1
Course 2
Course 3
Course 4
Course 1
Course 2
Course 3
Course 4
Course Name
Date Taken
Instructor
Course Name
Date Taken
Instructor
Course Name
Date Taken
Instructor
Course Name
Date Taken
Instructor
1 of 4
18
Course Certificate UploadPlease upload certificates of all the courses (MBL, Brain Gym, TFH, RMT,or 3 PLAY) you have attended. Note: You may skip this upload and continue to SUBMIT the form now, and use the "Edit" link in the email to upload your certs later.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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19
Spouse Name (as per IC)
First Name
Last Name
20
Spouse Gender
Male
Female
21
Spouse Nationality
Malaysia
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
22
Spouse Date of Birth
Date
Day
Month
Year
23
Spouse MyKad / IC / Passport No.
24
Spouse Email
example@example.com
25
Spouse Occupation
26
Spouse Phone Number
Please enter a valid phone number.
27
Spouse willing to serve as
Committee
Volunteer
Subcommitee
KL Area
Kajang Area
28
Child Details(Swipe left to enter more info)
Name
DOB
Gender
Strengths
Clinical Diagnosis
Current School
Child_1
Male
Female
Dyslexia
ADHD
Autism
Down Syndrome
GDD
Speech
Others - specify next page
Child_2
Male
Female
Dyslexia
ADHD
Autism
Down Syndrome
GDD
Speech
Others - specify next page
Child_3
Male
Female
Dyslexia
ADHD
Autism
Down Syndrome
GDD
Speech
Others - specify next page
Child_4
Male
Female
Dyslexia
ADHD
Autism
Down Syndrome
GDD
Speech
Others - specify next page
Child_1
Child_2
Child_3
Child_4
Name
DOB
Gender
Male
Female
Strengths
Clinical Diagnosis
Dyslexia
ADHD
Autism
Down Syndrome
GDD
Speech
Others - specify next page
Current School
Name
DOB
Gender
Male
Female
Strengths
Clinical Diagnosis
Dyslexia
ADHD
Autism
Down Syndrome
GDD
Speech
Others - specify next page
Current School
Name
DOB
Gender
Male
Female
Strengths
Clinical Diagnosis
Dyslexia
ADHD
Autism
Down Syndrome
GDD
Speech
Others - specify next page
Current School
Name
DOB
Gender
Male
Female
Strengths
Clinical Diagnosis
Dyslexia
ADHD
Autism
Down Syndrome
GDD
Speech
Others - specify next page
Current School
1 of 4
29
Child's Clinical Diagnosis / Behaviour to take note Please describe for each child mentioned on previous page.
Huge
Large
Normal
Small
Ok
Ok
30
Name of Company / Organization* This field is required.
31
Company / Organization Number (MyCoID)* This field is required.eg 1111451K
32
Organization Address
Street Address
Street Address Line 2
City
State
Zip Code
Malaysia
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
33
Person In-Charge* This field is required.
First Name
Last Name
34
Position in Company
35
Gender
Male
Female
36
Willing to serve as
Committee
Volunteer
Subcommitee
KL Area
Kajang Area
37
Member's Declaration* This field is required.I do hereby agree to the following: (must tick ALL)
to comply by the Constitution, Rules and Regulations of the Association, and
to participate actively in the Association's activities.

Membership Fee Structure

	New Member Registration Fee	Membership Fee	Renewal Fee	Lifetime Fee
Ordinary Member	RM 20	RM 50	RM 50	RM 500
Affiliate Member	RM 20	RM 50	RM 50	RM 500
Associte Member	RM 50	RM 100	RM 100	n/a

Please submit payment to bank account below:

Parents and Community Empowerment
United Overseas Bank (Malaysia) Bhd (UOB)
256-305-173-8

(for info purpose only, press NEXT when done viewing)

39
Fee to pay (in Ringgit Malaysia)Amount based on your choice of membership type. Please make payment via online or bank transfer, and take a photo to upload the transaction slip on next page.
40
Upload your payment transaction slipOrdinary memner RM50/year, Affiliate member RM50/year, Associate member RM100/year, NEW MEMBER registration add RM20 for Ordinary member, RM20 for Affiliate member and RM50 for Associate member)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Screenshot or pdf file.
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41
Signature
Clear
42
Membership NumberExample: M999-9999
43
Expiry Date
Date
Day
Month
Year
44
Membership Lifespan
Join Date
Termination Date
Ordinary Member
Associate Member
Affiliate Member
Life Member
Honorary Member
Initial Membership Type
Application Received by
45
Payment Record (office use only, update annually)* This field is required.2nd year and above are always renewal fee.
Payment Date
Registration fee
Mode of Payment
Membership Type
Total
Receipt No.
New_member
Cash
Bank Transfer
e-Wallet
Cheque
Ordinary Member
Associate Member
Affiliate Member
Life Member
Honorary Member
2nd_year
Cash
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e-Wallet
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Ordinary Member
Associate Member
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Life Member
Honorary Member
3rd_year
Cash
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Ordinary Member
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Affiliate Member
Life Member
Honorary Member
4th_year
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Ordinary Member
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5th_year
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6th_year
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Life Member
Honorary Member
7th_year
Cash
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Ordinary Member
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Affiliate Member
Life Member
Honorary Member
8th_year
Cash
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Ordinary Member
Associate Member
Affiliate Member
Life Member
Honorary Member
9th_year
Cash
Bank Transfer
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Cheque
Ordinary Member
Associate Member
Affiliate Member
Life Member
Honorary Member
10th_year
Cash
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Associate Member
Affiliate Member
Life Member
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New_member
2nd_year
3rd_year
4th_year
5th_year
6th_year
7th_year
8th_year
9th_year
10th_year
Payment Date
Registration fee
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Cash
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Membership Type
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Total
Receipt No.
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Cash
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Membership Type
Ordinary Member
Associate Member
Affiliate Member
Life Member
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Membership Fee Structure

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