Student Development & Alumni Relations Office

Student Activity: Indemnity / Permission to Stay Overnight on Campus Form

Note:
Please submit this form one day prior to activity. For clubs and societies, please submit this form to the respective SDAR Staff Advisor.

Organising Student Club/Society: ________________________________________________________

Title of Activity: ______________________________________________________________________
Nature of Activity: Overnight Stay / Overseas Expedition / Day Event / Others: ___________________
Start Date / Time of Activity: __________/________ End Date/Time of Activity: __________/________
Venue of Activity: _____________________________________________________________________
Country/City of Activity: _________________________________________________________________
Students Particulars:
Name: ____________________________________________ Division / School: ___________________
Student No: ____________________NRIC No: _______________ Handphone No: _________________
Blood Type: ___________________ Health/Medical Condition: ________________________________
Indicate Drug/Medicine you are allergic to: _________________________________________________
Address: ____________________________________________________________________________
___________________________________________________________ Postal Code: ____________
Parents / Guardians Particulars:
Name: ______________________________________________________________________________
NRIC No: _________________________ Relationship to student: _______________________________
Contact No: (Home Tel) ______________________(Handphone No:) ___________________________
Address: ____________________________________________________________________________
____________________________________________________________ Postal Code: ____________
To be completed by Parent / Guardian (Please delete where appropriate *)
I, the abovesaid parent / guardian hereby give permission for my * son / daughter / ward, the above said
student to participate in the * Overnight Stay / Overseas Expedition / Day Activity and I shall not hold
Ngee Ann Polytechnic, their appointed staff or officials responsible for any mishap, injury or loss of life
that may occur in the course of, or as a result of his / her participation in the abovesaid activity, and also
indemnify Ngee Ann Polytechnic and their appointed staff / officials against any claims, action,
proceedings, liabilities, damages or expenses by any party howsoever arising out of or in conjunction with
the above said activity.

___________________________
Signature by Parent / Guardian

_________________
Date
Updated on 5 May 2006