Indemnity Form (Co-Curricular Activities) printable pdf download

INDEMNITY FORM

(Co-Curricular Activities)

Name of Activity & Name of Club which Activity is to be conducted by:

Activity Date(s):

Sports for Life Programme - _________________ Module (eg. Bowling)

Start Date: 24 October 2016

End Date: 6 February 2017

Venue/Location:

Programme Coordinator:

Dept of Student Devt & Alumni Relations

(

), give

(NAME, parent/guardian*) _____________________

NRIC No./PPT No.

consent

and

declare

that

child/ward*,_______________________________________

(

NAME

____________________ (

) is FIT to participate in the above activity conducted by Singapore Polytechnic,

NRIC No./PPT No.

its servants and organisers.

TERMS AND CONDITIONS

1. All

students

are

advised

undergo

medical

examination

prior

the

start

the

programme/training/activity/camp. All students must be medically, mentally and physically able to participate in the

programme/training/activity/camp throughout the entire duration of their involvement.

2. All students acknowledge that some of the activities may involve a significant degree of physical exertion and

physical risk.

3. All students should ONLY participate when there is a qualified instructor/appointed personnel supervising the

programme/training/activity/camp. In the event of additional programme/training/activity held without qualified

instructor/appointed personnel, students must ensure that:

3.1 They inform parents and officer-in-charge on all unofficial programme/training/activity (day/time/venue).

3.2 They are responsible for their own safety during unofficial programme/training/activity.

3.3 There are no clashes in venue/equipment with other CCA groups.

4. Subject to applicable law, Singapore Polytechnic will not be held responsible for any personal injury, death, and/ or

any other consequential misfortune/accident/loss/damage that may arise in the course of the programme.

(1)

Note:

(1) SP has obtained insurance policies for personal injury and/or public liability covering the students in the course of the

programme. More details can be made available on request

I have read and understood the above terms and conditions. I am aware of the possible risks involved and accept the

same. I confirm that I am enrolling my child/ward* on my own volition and, subject to applicable law, shall not hold the

Singapore Polytechnic, its servants and organisers responsible or in any way liable for my child’s/ward’s* personal injury,

death, and/or any other consequential misfortune/accident/loss/damage whatsoever arising from any cause in

connection with the programme/training/activity/camp. In the case of withdrawal from the programme, I agree to pay

for any administrative/cancellation charges/cost incurred.

I grant my consent for my personal particulars to be collected and used and where applicable disclosed by Singapore

Polytechnic to the relevant authorities/parties, for example, Ministry of Education, Ministry of Foreign Affairs, Ministry of

Defence (MINDEF) etc. to facilitate programme execution, travel notices and for emergencies purposes etc.

Parent’s/Guardian’s Signature : ___________________

Student’s Signature

: ________________________

Parent’s/Guardian’s Contact No.: ___________________

Student’s Name

: ________________________

Parent’s/Guardian’s Email: ________________________

Student’s Admin. No. : ________________________

Date: ________________

DSA-FRM-026E

Release 1.0

Indemnity Form (Co-Curricular Activities)

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