Appendix I

[To print on Student Organisation’s Letterhead]

FRESHMEN ORIENTATION CAMP 2012

SENIORSREGISTRATION AND INDEMNITY FORM

Camp Name:

Student Organisation:

Camp Dates:dd/mm/yy – dd/mm/yy

  1. PARTICIPANT’S PARTICULARS

Name (as in passport)
NRIC Number (Singaporeans/PR)/
Passport Number or FIN (Foreigners)
(If you are a student)
School / Course / Year of Study
(If you are an alumnus)
Organisation / Position
Position in Camp
(pls check – unchecked applications shall be rejected) I shall ensure tobe fully aware about my responsibility and allrules, regulations, requirements and instructions governing the Freshmen Orientation Camp from the Camp Organiser, and abide by them strictly.
Gender (pls circle) / Male / Female / Date of Birth
(dd/mm/yy)
Mailing Address
Postal Code / S
Contact No / (home) / (mobile)
Email Address / Blood Group
Allergies, Illnesses & Medical Limitations(pls declare):
Dietary Requirements / Halal / Vegetarian / No restriction
T-shirt Size / XS / S / M L / XL
  1. PERSON TO NOTIFY IN CASE OF AN EMERGENCY

Name / Relationship
Mailing Address
Postal Code / S
Contact No / (home) / (mobile) / (office)
Email Address

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  1. TYPES OF ACTIVITIES AND POSSIBLE INJURIES

Programmes of FOCs may include physical and team-building activities. Some possible injuries includecuts, bruises, sprains, muscle strains, andheat exhaustion.

Safety is our primary concern and we take all precautionsto guard against injury. If you are not feeling well or have sustained an injury, please inform the Camp Organiser or First Aider immediately.

If you have a medical history or an existing medical condition and are not certain if you can participate in the more rigorous activities, please refrain from participating until you have sought clearance from your doctor. Please note that the cost of any medical treatment is to be borne by the participants.

INDEMNITY FORM (to be signed by participant)

I acknowledge and agree that participation in ______(Camp Name)comes with inherent risks. I have full knowledge of the foregoing risks and assume all such risks myself.

In consideration of my participation in the ______(Camp Name), I shall not hold______(student organisation), Nanyang Technological University, its officers, agents and employees liable for any damage to or loss of property or any injury or loss of life where such damage to or loss of property or any injury or loss of life is not caused by the negligence of ______(student organisation), Nanyang Technological University, its officers, agents and employees.

I undertake to ensure strict compliance with all rules, regulations, requirements and instructions related to ______(Camp Name).

I understand that, should I be admitted to ______(Camp Name)on the basis of any false or inaccurate information declared by me, I may render myself liable to any appropriate action and such false or inaccurate declaration may result in the voidance of any insurance claim arising from or in connection with ______(Camp Name).

______

Name of participantSignatureDate

Parent’s or Guardian’s Undertaking (To be completed if the participant is below the age of 21 years)

I, being the parent, guardian or person having the care and custody of ______(name of participant), do consent that s/he may participate in ______(Camp Name), and, in consideration of ______(student organisation), Nanyang Technological University, its officers, agents and employees permitting him/her to so participate, undertake that I will not, whether on behalf of my child / ward or in my own right, hold ______(student organisation), Nanyang Technological University, its officers, agents and employees liable for any damage to or loss of property or any injury or loss of life where such damage to or loss of property or any injury or loss of life is not caused by the negligence of Nanyang Technological University, its officers, agents and employees.

______

Name of parent, guardian/person having SignatureDate

the care and custody of the participant[Page 2 of 2]

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