OVERSEAS TRIP

APPLICATION FORM FOR PARTICIPANT

YOUTH EXPEDITION PROGRAMME – CAMBODIA - SEPTEMBER 2008

APPLICANT’S PARTICULARS ( Part A )

Name (as in passport and underline surname): / NRIC No: / Note: if your passport is going to expire before 1 April 2009, you will need to extend/renew it before you go on this programme.
Nationality
(Please indicate if you are a Singapore PR): / Passport No (if different from NRIC)
Place of Issue / Date of Issue: / Date of Expiry of passport
Student No: / Course/ Level: / Module/ Mentor Group:
Sex: / Date of Birth: / Marital Status:
Religion: / Blood Type (if known): / T-shirt Size: / E-mail:
Home Address: / Home Tel No:
Pager/ Handphone:
Name of Next of Kin (NOK) / Relationship to Applicant:
NOK Contact No:
Office/ Handphone/ Pager/ E-mail / Own swimming Ability:
Good/ Average/ Poor
Medical History (Circle where necessary)
Heart Problem / Fits / Fainting Spell / Diabetes / Asthma / Migraine / Vision Problem / Colour Blind / Ear problem / Fractures / Dislocations / Carrier Status / None
Current Medication: / Dietary Requirements/ Food Restrictions:
None / Vegetarian / Halal / No Seafood
Other Medical/ Physical Conditions/ Allergies:
ACADEMIC/ CCA (Part B)

Past CCA records and any other hobbies or talents

CCAs In Ngee Ann Polytechnic
Have you attended any overseas programme with NP? YES / NO
If YES, please specify: (Programme and country)
In what capacity: Participant / Students Leader / Others
If Others, please specify:

I agree to:

a)  Abide by all rules stated in the safety guidelines and trip pamphlet.

b)  Follow all instructions given by any of the staff-in-charge, local guides/ instructors, park rangers, or any appointed personnel on duty during the trip.

c)  Declare all necessary information regarding my personal health and skills to the staff-in-charge before or during the trip.

d)  Be responsible for my personal safety at all times throughout the trip.

e)  Pay NgeeAnn Polytechnic the FULL cancellation charges and expenses incurred if I withdraw or fail to show up for the trip.

______

Name/ Signature: Applicant Name/ Signature: Parents/ Guardian Date

(If participant is below 21 years old)

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INDEMNITY FORM (Part C)

PART 1 – If you are below 21 years of age, please ask your parent/ guardian to complete and sign this section
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 YEP to Cambodia, 2008 organised by the School of Life Sciences & Chemical Technology, Ngee Ann Polytechnic.
I, ______, NRIC/Passport No ______agree that I shall not hold the Ngee Ann Polytechnic, the participating organisations 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 YEP to Cambodia, 2008 organised by the School of Life Sciences and Chemical Technology, Ngee Ann Polytechnic.
I shall also indemnify Ngee Ann Polytechnic, the participating organisations 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 – If you are above 21, please complete this part of the form and sign.

I, ______, NRIC/Passport No ______agree that I shall not hold the Ngee Ann Polytechnic, the participating organisations 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 YEP to Cambodia, 2008 organised by the School of Life Sciences and Chemical Technology, Ngee Ann Polytechnic.
I shall also indemnify Ngee Ann Polytechnic, the participating organisations 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

YEP Cambodia 2008 Page 1 of 3