Student Development & Alumni Relations Office

Student Activity: Indemnity / Permission to Stay Overnight on Campus

Form

Note:
Please submit this form one day prior to activity. For clubs and societies, please submit this form to the
respective SDAR Staff Advisor.

Organising Student Club/Society: Aerobics

Club____________________________________________

Title of Activity: Aerobics Bonding

Camp__________________________________________________

Nature of Activity: Overnight Stay / Overseas Expedition / Day Event / Others:

___________________

Start Date / Time of Activity: 03 Nov 2017/1800h End Date/Time of Activity: 05 Nov
2017/1800h

Venue/City/Country of Activity: School Campus

Students Particulars:

Name: ____________________________________________ Division / School: ___________________

Student No: ____________________NRIC No: _______________ Handphone No:

_________________

Blood Type: ___________________ Health/Medical Condition:

________________________________

Indicate Drug/Medicine you are allergic to:

_________________________________________________

Address / Postal Code: _________________________________________________________________

Parents / Guardians Particulars:

Name: __________________________________________ NRIC No: ___________________________

Relationship to student: _____________________Contact:____________ (Home Tel)

___________(hp)

Address / Postal Code: _________________________________________________________________

To be completed by Student
I wish to participate in the above activity. I understand that the Polytechnic takes
measures and puts in place precautions to ensure the safe conduct of all
programmes and activities. It also has in place emergency handling procedures in
the event of any incident. However, I agree that safety is everyone's responsibility. I
will cooperate with the Polytechnic, its staff and other agents and comply with all
Updated 20 Mar 2015 SDAR-NP-013
health and safety instructions issued through or by them at all times. It is my
personal responsibility to inform the Polytechnic's event organisers of any mental or
physical health condition that may affect my participation in any event before my
participation. I can also report any safety issues using the following hotline 6460
6999. At all times, I will make safety my first priority.

___________________________ _________________
Signature by Student Date

To be completed by Parent / Guardian* (Please delete where appropriate *)

I consent to my child's/ ward's* participation in this activity. I have explained to my
child/ ward the importance of knowing and abiding by all NP directives, rules,
regulations, and procedures, including all directions issued by NP staff and other
agents for the safety of all participants. I confirm that all the information provided
here is true.

___________________________ _________________
Signature by Parent / Guardian Date

Updated 20 Mar 2015 SDAR-NP-013