REGISTRATION FORM

(Small Group Self-Help Class)

Section A: Course Application Details
Course Title:
Conducted by:
Start Date: End Date:
Time:
Section B: PersonalParticulars (* Mandatory Fields)
*Name in NRIC: / *NRIC No:
*Date of Birth: / (dd/mm/yyyy) / *Gender: / Male Female
*Race: / Chinese Malay Indian Others:(pls specify)
*Citizenship: / Singapore Singapore Permanent Resident
Others:(pls specify)
Email (if any):
*Mobile No: / *Home No:
*Address:
Marital Status: / Single Married Widowed Separated/Divorced
Educational Level: / Primary Secondary Post-secondary (JC/ITE) Diploma
Bachelor’s Degree Masters/Doctorate Others:(pls specify)
Work Status : / Self-employed Employed full-time Employed part-time
Homemaker Unemployed Retired
Religion: / Buddhism Taoism Islam Hinduism Sikhism
Roman Catholic Christianity No Religion
Others:(pls specify)
Housing Type: / HDB 1-2room HDB 3room HDB 4room
HDB 5room/Executive Condominium/Private Landed
Others:(pls specify)

Initiated and supported by C3A.

Council for Third Age (C3A) was set up in May 2007 with the role of promoting active ageing in Singapore. C3A aims to create a vibrant pro-age Singapore through education, outreach and partnership – a society where seniors can participate as integral members according to their interests and abilities, and ultimately fostering a society where seniors live full, active and meaningful lives.

C3A senior teachers are mature volunteers who are responsible for organizing and facilitating a course on a variety of topics. These programs target mature senior learners where interactive teaching and learning in an open, self-help, respectful and co-operative community spirit of engagement are encouraged and promoted.

Dear Participant,

Part 1Use of Contact Information

By submitting this form, I consent to receiving relevant information on programmes, events, surveys and promotions relating to active living for seniors from Council for Third Age and I agree to Council for Third Age’s privacy policy.

I understand that I may update my personal data or withdraw my consent at any time by emailing . The privacy policy may be viewed at

Part 2 Use of Photographs and Videos

Do note that photographs and videos may be taken during the programme for news and publicity purposes.

Part 3Statement of Undertaking

By signing this statement of undertaking, I, the participant, warrant that I have read, understood and agreed to the following:

  1. Course is conducted by the senior teacher (the “trainer) at the invitation of C3A.
  1. Registration for the course named above is on a first-come, first-served basis.
  1. I agree to exercise care and respect to my classmates and to the senior teacher (the “trainer”) during class discussion and interaction.
  1. I agree to exercise care and proper use of the facilities at the premise arising in connection with this course.

Name & SignatureDate

SGSH Registration Form8 Aug 2014Pg 1 of 2