Spprimers Indemnity Form (ipod)

INDEMNITY FORM I wish to join the _______IPOD 2009_______ (trip/activity/camp) organised by ______sp primers____ from ____24/10/2009_____ to ______24/10/2009___ and abide by the Rules and Regulations set by both the Singapore Polytechnic and the Event Organising Committee. I am fully aware of the possible risks involved and accept the same, notwithstanding the fact that this trip/activity/camp is intended only for those without medical problems and who are fit enough to indulge in physical activities. I confirm that I am enrolling on my own volition and I shall not hold the Singapore Polytechnic, its servants and organisers responsible or in any way liable for my death, injury, disability or any loss or damage whatsoever arising from any cause in connection with the trip/activity/camp or my participation therein. I hereby indemnify and agree to keep the Singapore Polytechnic, its management, servants and organisers of the event fully indemnified against all claims, loss or damage whatsoever in respect of death, injury, disability or any loss or damage whatsoever arising from any cause in connection with the trip/activity/camp or my participation therein. Personal Particulars Name :

Gender* : Male / Female

Address : Adm No :

Course/Class: __________________ NRIC no. :

Email :

Date of Birth :

Home No :

Handphone No:

_______________________ __________________ Signature Date ……….…………………………………………………………………………….…………………… Parent’s/Guardian’s Consent for Participant below 21 years of age on date of the Enrolment I consent to the above applicant, who is my child/ward* participating in the above trip/activity/camp and accept all legal and other responsibilities connected with the trip/activity/camp, as outlined above. I hereby indemnify and agree to keep the Singapore Polytechnic, its management, servants and organisers of the event fully indemnified against all claims, loss or damage whatsoever in respect of my child’s/ward’s death, injury, disability or any loss or damage whatsoever arising from any cause in connection with the trip/activity/camp or his/her participation therein. __________________________________ Full Name of Parent/ Guardian* ______________________ NRIC/Passport* No

_____________________ Signature

______________________________ Contact No. (in case of emergencies)

_______________ Date

* Please delete accordingly

SAA-FRM-935 Indemnity Form

Release 3.0