REPUBLIC POLYTECHNIC

CONSENT FORM
(Participant’s Confidentiality will be exercised when completed)

PROGRAMME INFORMATION (to be filled up by RP staff in-charge)

Programme Name: M202 Media Writing Industry Project – Chingay 2017

Duration of
Date of Programme: 4 weeks
14/1/2017 TO 12/2/2017 Programme:
Staff In-Charge Contact No.:
EUGENE LIM 9685-8686
Name: (preferably mobile no.)

PARTICIPANT INFORMATION (to be filled up by participant)

Full Name: Student ID: NRIC/FIN No.:
(Underline surname) (if applicable)

School / Centre:  SAS  SEG  SOH  SHL Diploma / Course Name:

(please tick, if  SOI  STA  CEC (if applicable)
applicable)

Date Of Birth: / / Age: Gender:  Male  Female

Home Address:

Contact No. (Home): Contact No. (Mobile):

Dietary Preference:
(Not applicable for 1 day programme) NIL

EMERGENCY CONTACT INFORMATION (to be filled up by participant)

Relationship
Name of Emergency
with
Contact Person:
participant:

Contact No.
Home Address: (Home):
(Indicate “same as above”, if
address is identical to the above
section)
Contact No.
(Mobile):

Republic Polytechnic
Programme Consent Form | June 2012
Page 1 of 4
 MEDICAL DECLARATION (to be filled up by participant)
Blood Group:  A+  A-  B+  B-  AB  O-  O+  Not known
(please tick)

If YES, please give more information e.g. history,

Do you have any: last occurrence or what needs to be noted.
Yes No
Please refer to Annex 1 for conditions that
require a doctor’s clearance.
Allergies (food, medicines, insects,
1.
plants etc)
Asthma – long term medication /
2.
exercise-induced
3. Diabetes
Heart trouble (E.g. MV prolapse with
4.
regurgitation)
High blood pressure – long term
5.
medication
6. Kidney disease
Other health conditions (E.g.
physical or mental disability that
7.
may affect your participation in the
programme)

ACKNOWLEDGEMENT
( TO BE FILLED UP BY PARTICIPANT IF PARTICIPANT IS 21 YEARS OLD AND ABOVE, OR PARENT/GUARDIAN IF
CHILD/WARD IS BELOW 21 YEARS OLD )

Acknowledgement of Risk & Consent

I understand and acknowledge the risks associated with and related to my / my child’s/ ward’s participation in the
programme conducted by Republic Polytechnic (RP). I understand that I / my child/ward will cooperate fully with the RP
staff(s) and diligently comply with all instructions and safety regulations. I declare and confirm that I have read fully
understood all the parts in this form and I hereby accept the risk involved in the activities conducted as disclosed in the
information provided by RP. I further declare and confirm that all the information provided herein is true and ratify the
Medical Declaration and Undertaking given by me or my child/ward. I agree to not hold RP, its affiliated partners and
staff liable for any injury (including death of) or loss of or damage to the property suffered by me /my child/ward related
in whole or in part to this programme, where the injury, death, loss or damage is not directly caused by the wrongful or
negligent act or default of RP, its affiliated partners and its staff.

Participant Medical Declaration

I acknowledge that I have read and fully understood this declaration prior to signature. I confirm and declare that the
information provided above is true to the best of my knowledge.

NRIC No. of Parent

Name of Parent / Guardian:
/ Guardian:

Signature: Date:
*Parental signature required only for participant below 21 years old.

Name of Participant:

Signature: Date:

Republic Polytechnic
Programme Consent Form | June 2012
Page 2 of 4
 FITNESS ASSESSMENT BY MEDICAL DOCTOR
(*ONLY IF APPLICABLE)
*Please refer to Annex 1 for some of the conditions that warrants a doctor clearance

Notes for Participant or Parent / Guardian

1. Please refer to Annex 1 (Participant’s Information) of the Registration Form when completing this form.
2. You are advised to inform your doctor if you have any allergies or any medical and physical condition. It will
help us look after you better.
3. RP undertakes to safeguard your personal information. RP will only use this information solely for evaluative
and safety-related purposes, for participation in the above-mentioned activity. The personal information
(including medical information) shall be used solely for that purpose and will not be disclosed to any other
parties.
4. Please bring this form to the doctor for assessment. The completed form should be submitted to the staff in
charge before the commencement date of the course.

To Be Completed By Medical Doctor

1. I have on this date _____________ examined __________________________(name)

NRIC No./Passport No. ______________________ and find him/her* fit/unfit* to participate in the RP
Programme from _____________________ to ______________________(date).

2. This participant has no known allergy* to the following:

(a) Medicine
_______________________________________________________________
(b) Food
_______________________________________________________________
(c) Others
_______________________________________________________________

3. His/Her* special condition/previous injury* requiring attention is as follows:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
*Delete where applicable

Doctor’s Name: Signature:

Clinic Stamp: Date:

Republic Polytechnic
Programme Consent Form | June 2012
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 Annex 1

IMPORTANT INFORMATION FOR APPLICANT

Some of the programmes in RP are conducted indoors as well as outdoors, in all weather conditions and would involve participants
in water and height activities such as rock-climbing, kayaking, ropes courses, rafting and group initiative games.

Many attend our courses or programmes in spite of medical constraints and Republic Polytechnic encourages and
supports this effort and commitment. It is however important that we know of any problem area(s) as it is in your interest and
ours. If you are receiving medication and/or have any of the following illnesses, it will prohibit your full participation in the course,
thus a doctor’s clearance is needed:

01. Hypertension - On long term medication;

02. Asthma - On long term medication/Exercise induced;
03. Severe allergy - To grass, sea-water, dust and insects;
04. Anaemia - Hb below 11gm %;
05. Epilepsy - Any attack within the last three years;
06. Severe Obesity;
07. Thalassaemia Major;
08. Recurrent dislocation of shoulder;
09. Mitral Valve Prolapse with Regurgitation;
10. Pregnancy; and
11. Any Other Physical or Mental Disability that may affect your participation in the course.

To help us ensure your safety, please complete the Medical Declaration By Applicant questionnaire fully and honestly. All
information provided on the form will be treated as CONFIDENTIAL.

Important Note

Tetanus Immunisation is strongly advised if there is an interval of 10 years since either your last Booster Dipthera-Tetanus or
Tetanus Immunisation.

If you contract any illness or disease between submission of the Medical Declaration Form and the commencement of the Course,
it is important that you consult a doctor and keep the RP staff in charge of the programme informed.

Republic Polytechnic
Programme Consent Form | June 2012
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