XXXXXXXX Conference

(the “Programme”)

INDEMNITY FORM

(A) PERSONAL PARTICULARS

1. Full Name (underline or capitalise last name): / 7. Home Contact Number: ______
______Gender: F / M / 8. Mobile Contact Number: ______
2. NTU Matriculation Number: ______/ 9. Email Address: ______
3. NRIC / Passport Number: ______/ 10. Alternate Email Address: ______
4. Nationality (Country of Passport): ______/ 11. Full Address: ______
5. Singapore Permanent Resident: Yes / No / ______
6. Date of Birth (DDMMYYYY): ______/ ______

(B) PROGRAMME DETAILS

1. Name of Host University / Conference : ______
2. Country of Host University / Conference: ______
3. Address of Host University / Conference Venue: ______
4. Overseas Duration: From: ______To: ______

(C) FLIGHT DETAILS

Date of Departure from Singapore : ______
Departure Flight (Airline and Flight #): ______
Arrival date and time at Destination :______
Date and Time of Return Flight: ______
Return Flight (Airline and Flight #): ______
1st EMERGENCY CONTACT / 2nd EMERGENCY CONTACT
Name: ______/ Name: ______
Relationship to Applicant: ______/ Relationship to Applicant: ______
Address: ______/ Address: ______
______/ ______
Contact No: ______(Home) / Contact No: ______(Home)
______(Office) / ______(Office)
______(Handphone) / ______(Handphone)

(D) DECLARATION

1. I hereby declare that I have taken up thisProgramme of my own accord.

2. I agree to assume any and all risks which might be associated with this Programmeand I will not hold the Nanyang Technological University (‘NTU’) and its officers, or any of its full-time or part-time staff responsible or liable in any way for and that no right of action shall arise from, any loss or damage (including, without limitation, personal injury or property damage) caused by or sustained as a result of my participation in the Programme.

3. To the extent permitted by law, I will indemnify NTU and keep NTU indemnified from and against all liabilities, claims, actions, damages, costs or expenses of any type arising out of or in any way connected with the Programme or breach of my undertakings herein.

4. I agree to comply with all applicable rules/regulations, instructions and requirements as may be prescribed from time to time by NTU and/or the Host University/Host Organisation/Conference Organizer.

5. I will, at my own expense, effect and maintain adequate insurance in respect of medical and accident expenses and, where required, any third party or public liability arising out of the Programme.

6. I am able to meet the financial commitments required to participate in the Programme.

7.I declare that I am sufficiently fit physically to participate and complete the Programme and that I have not been advised otherwise by a qualified professional.

(E) WARNING

Anyone found to have consumed illegal substances, even outside Singapore, will face the penalty of imprisonment of up to 10 years, fine not exceeding $20,000, or both.

(Applicable only to students from Singapore)

Signature of Applicant:______Date: ______

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