Student Activity: Indemnity / Registration Form

Organising Student Club/Society: ICT Academic Society Title of Activity: 3DO BONDING CAMP Nature of Activity: FRESHMEN 3-DAY 2-NIGHT BONDING CAMP Students Particulars: Name: Student No: Blood Type: NRIC No: Health/Medical Condition: Handphone No:

Indicate Drug/Medicine / Food you are allergic to: Address: Postal Code: Parents / Guardians Particulars: Name: NRIC No: Contact No.: (Home Tel) Relationship to Student: (Handphone No.)

To be completed by Parent / Guardian (Please delete where appropriate *) I, the above said parent / guardian hereby give permission for my * son / daughter / ward, the above said student to participate in the 3DO Bonding Camp (with overnight stay) 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 above said 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 10 March 2011