INDEMNITY FORM

I wish to join the ________________________________________________________________

from _________________ to _________________ and abide by the Rules and Regulations set by both
the Singapore Polytechnic and the Event Organising Committee. I am fully aware of the possible risks
involved and accept the same, notwithstanding the fact that this course/activity/trip is intended only
for those without medical problems and who are fit enough to indulge in physical activities. I confirm
that I am enrolling on my own volition and I shall not hold the Singapore Polytechnic, its servants and
organisers responsible or in any way liable for my death, injury, disability or any loss or damage
whatsoever arising from any cause in connection with the course/activity/trip or my participation
therein.

I hereby indemnify and agree to keep the Singapore Polytechnic, its management, servants and
organisers of the event fully indemnified against all claims, loss or damage whatsoever in respect of
death, injury, disability or any loss or damage whatsoever arising from any cause in connection with
the course/activity/trip or my participation therein.

Personal Particulars

Name : Gender* : Male / Female

Address :

Adm No : Course/Class: __________________ NRIC no. :

Email : Date of Birth :

Home No : Handphone No:

_______________________ __________________
Signature Date
……….…………………………………………………………………………….……………………
Parent’s/Guardian’s Consent for Participant below 21 years of age on date of the Enrolment

I consent to the above applicant, who is my child/ward* participating in the above camp and accept all
legal and other responsibilities connected with the course/activity/trip, as outlined above.

I hereby indemnify and agree to keep the Singapore Polytechnic, its management, servants and
organisers of the event fully indemnified against all claims, loss or damage whatsoever in respect of
my child’s/ward’s death, injury, disability or any loss or damage whatsoever arising from any cause in
connection with the course/activity/trip or his/her participation therein.

__________________________________ _____________________
Full Name of Parent/ Guardian* Signature

______________________ ______________________________ _______________

NRIC/Passport* No Contact No. (in case of emergencies) Date
* Please delete accordingly

SAA-FRM-935 Release 2.0

Indemnity Form
 Passport to a Colorful Life
PRIMERS ORIENTATION CAMP 09

Packing List
ITEM QTY CHECKED?
Clothings
T-shirts (Dark colored) 03
Bottoms 03
Undergarments Sufficient
Sandals/Slippers 01
Covered shoes (compulsory) 01
Covered shoes / booties (for wet activities) 01
Swimwear (as inner clothing during kayaking) 01
Jacket (optional) 01
BB Polo Tshirt (for seniors) 01
Toiletries
Toothbrush/paste 01
Shampoo 01
Shower foam 01
Towel 01
Deodorant (optional) 01
Powder (optional) 01
Personal
Personal medications If applicable
Inhaler (for asthmatic) If applicable
Insect repellent (advisable) 01
Torchlight (optional) 01
Contact lens solution If applicable
Miscellaneous
Writing materials Sufficient
500ml water bottle (compulsory) 01
Goggles (optional) 01
Snacks (recommended) Sufficient
 Registration & Consent Form

Section A: Volunteer’s Particulars1

(As in NRIC / Passport)

Full Name in
Race:
BLOCK Letters:

NRIC / FIN No: Gender: Female / Male

Date of Birth:
Age:
(DD/MM/YYYY)
Height (cm) Weight (kg)

Email Address: Religion:

Home Address:

Home Tel No: Mobile No:

Name of
Employer /
School:
Special Dietary
Requirements Halal / Vegetarian / Others (Pl specify: __________________)
(if any):
MEDICAL BACKGROUND
Have you been or are you currently affected by any of the following? (Please circle)

Diabetes Yes / No Ear Problems Yes / No

Asthma Yes / No Back Problems Yes / No
Low Blood Yes / No Neck Problems Yes / No
High Blood Yes / No Joint Problems Yes / No
Coronary Problems Yes / No Bone Fractures Yes / No
Eye Problems Yes / No Muscle Problems Yes / No
Other condition(s) affecting or restricting you:

Are you on medication / prescribed drugs? Yes / No (Please circle)

If “Yes”, please elaborate:

Had surgery done within the last 2 years? Yes/ No (Please circle)
If “Yes”, please elaborate:

Allergies? Yes/ No (Please circle)

If “Yes”, please state:

1
Please email a passport size photograph to Kelly Low ( kelly.low@touch.org.sg )
Section B: Acknowledgement of Volunteer

I, _______________________________ holder of NRIC/ Passport No: __________________

am aware that my participation in the National Day Parade 2009 with TOUCH Community
Services (TCS) and related training involves certain amount of risks. I understand that I will
have to co-operate fully with the staff and diligently comply with all safety systems. I shall
therefore not hold TCS or their servants and agents responsible for any damage to or loss of
property or any injury or loss of life which may be sustained by myself during the event or
arising from or in connection with the event where such damage to or loss of property or any
injury or loss of life is not caused by the negligence or wilful act or omission of TCS.

Signature: ________________________ Dated: (DD/MM/YYYY)

Section C: Acknowledgement and consent of Parent / Guardian

(For Volunteer below 21 years old)

I, _______________________________ holder of NRIC/ Passport No: __________________

hereby allow my *child/ward, _______________________________ (Full name) to participate
in the National Day Parade 2009 with TOUCH Community Services (TCS).

I am aware that my *child’s/ward’s attendance in the event and related training involves
certain amount of risks. I understand that my *child/ward will have to co-operate fully with the
staff and diligently comply with all safety systems. I shall therefore not hold TCS or their
servants and agents responsible for any damage to or loss of property or any injury or loss of
life which may be sustained by *my child/ward during the event or arising from or in
connection with the event where such damage to or loss of property or any injury or loss of life
is not caused by the negligence or wilful act or omission of TCS.

Signature: ________________________ Dated: (DD/MM/YYYY)

Section D: Contact Person (in the event of emergency)

Name of Contact Person:

Relationship to volunteer:
Contact No:

Address:

*delete where not applicable