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