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Registration & Consent FormSection A: Volunteer’s Particulars
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Full Name inBLOCK Letters:(As in NRIC / Passport)Race:NRIC / FIN No: Gender: Female / MaleDate of Birth:(DD/MM/YYYY)Age:Height (cm) Weight (kg)Email Address: Religion:Home Address:Home Tel No: Mobile No:Name of Employer /School:Special DietaryRequirements(if any):Halal / Vegetarian / Others (Pl specify: __________________)
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:
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Please email a passport size photograph to Kelly Low (kelly.low@touch.org.sg)
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