NGEE ANN POLYTECHNIC CCA SPORTS CLUBS HEALTH DECLARATION FORM

(1) Personal Particulars Name (in Full): Student Number : Name of CCA Club: (2) Medical Information Existing Medical Condition(s) : Yes/No If yes, please list: Gender: Contact Number: Male / Female

Any Drug Allergy: Yes/No If yes, please list:

List all Medications you are taking regulary:

List History of past injuries eg. Dislocated shoulder

3. Parental Consent

I, ____________________________________ (Name), _________________________ (NRIC NO) certify that the above information of my child are true and correct and that I do not permit / permit him/her to join the above listed sports CCA Club in Ngee Ann Polytechnic.

Name of Parent/Guardian

Contact Number

Signature/Date

Submitted by Club Management Comm :

Staff Advisor's signature and date : *Health Declaration Form is to be submitted to the Management Committee of the Sports CCA Club for endorsement by the Staff Advisor