Rp Camp Form

Registration Form Self-esteem building(Mind Champs) 2009 I wish to register for the Self Esteem Camp (15-17 December 2009) Name:____________________________________________ Sex: M / F Contact Numbers:(HP) __________________________________________ (H) ____________________________________________ E-mail: ______________________________________________________ Next-of-kin contact: Name: ______________________________ Relationship:________________ Contact Numbers (HP)______________________ (H)____________________ (O) ______________________ _______________________________________________________________ Course: Food requirements: Vegetarian / Halal / None (Circle as appropriate) Pre-existing medical conditions: (e.g. allergy to mud etc) _______________________________________________________________ _______________________________________________________________ Please return this form with the registration fee( $150) to the camp commandant on the 14th of December 2009. For more details contact Mr. Naidu at 97115907. Further details will be given to you upon registration INDEMNITY FORM PLEASE READ THE FOLLOWING CAREFULLY If you are below 21, please ask your parent/guardian to fill in and sign PART A . If you are above 21, please fill in and sign PART B.

PLEASE REMEMBER TO FILL IN THE CONSENT/INDEMNITY FORM

PART A – To be completed by your parent/guardian if you are below 21. I , (name of guardian / parent)_________________________,(NRIC / passport No.)___________ being the (relationship)________________of (student’s name) ______________________agree to allow my son/daughter/ward* to participate in the Self Esteem Camp December 2009 organized by the Mind Champs @ Republic Polytechnic. I, ______________________, NRIC/Passport No ____________________ agree that I shall not hold the Republic Polytechnic, the participating organizations i.e. the host, and/or their appointed staff or officials responsible for any mishaps, injury or loss of life that may occur in the course of, or as a result of my child’s/ my ward’s participation in the Self Esteem Camp December 2009 organized by the Mind Champs @ Republic Polytechnic. I shall also indemnify Republic Polytechnic, the participating organizations i.e. the host, and/or their and their staff against any claim by any party for damages or compensation whatsoever in the event of any injury or death by my child/my ward named above.

______________________ Signature of parent/guardian & date * delete where appropriate PART B – To be completed by yourself if you are above 21 I, ______________________, NRIC/Passport No ____________________ agree that I shall not hold the Republic Polytechnic, the participating organizations i.e. the host, and/or their appointed staff or officials responsible for any mishaps, injury or loss of life that may occur in the course of, or as a result of my participation in the Self Esteem Camp December 2009 organized by the Mind Champs @ Republic Polytechnic I shall also indemnify Republic Polytechnic, the participating organizations i.e. the host, and/or their and their staff against any claim by any party for damages or compensation whatsoever in the event of any injury or death by myself named above.

______________________ Signature of student & date

PLEASE REMEMBER TO FILL IN THE CONSENT/INDEMNITY FORM