Health Declaration & Indemnity Form

1

Name of Event / Activity: NUS Business Orientation Week


Information about Yourself
1. Name (as it appears in your NRIC/Passport): ____________________

2. NRIC/FIN/Passport number: ____________________

3. Blood Type: ____________________

4. Matric No: ____________________

5. Date of birth (dd/mm/yy): ____________________

6. Home Address: ____________________

7. Contact no: ____________________

9. Gender: Male / Female


Medical Self-Declaration

12. Do you have/require:


a. Chest pains, high blood pressure or heart
problems e.g. heart murmur, extra
heartbeat, mitral valve prolapse?

b. Asthma, bronchitis, tuberculosis, sinusitis
or other lung problems?

c. Fits, epilepsy, fainting spells, migraine,
severe head injury?

d. Eye problems e.g. poor vision?

e. Ear problems e.g. hearing difficulty?

f. Nervous illness?

g. Diabetes / Thalassaemia major / Anaemia?

h. Bone or joint injuries e.g. fracture /
dislocation?

i. A carrier status for any infectious disease?

j. Medical treatment within the last two years?

k. Routine medication?

l. Any form of disability?

m. Any other medical information of note e.g.
Specialists letter/note (pls attach);
pregnancy

n. Any allergies?

No Yes If Yes*, please give further
information eg. history, last
known occurrence, restriction of
movement etc.
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* If answer is Yes for any of the above questions, the organizer may require a doctors note or memo to
certify the participant is fit for the event / activity concerned.








Health Declaration & Indemnity Form

2

Emergency Contact Information

13. Name of contact person: ____________________

14. Relationship to you: ____________________

15. Contact no: ____________________ (Home) ____________________ (Mobile)

16. Home address: ___________________________________________________


Undertaking & Indemnity


Part 1
a. I declare that all the information provided above is true.
b. I will ensure that at any time, Im medically well and physically fit to undertake the rigors as required by
the event / activity.
c. I shall dutifully report to the organizers:
i Of any physical discomfort that may arise out of my involvement in the event / activity.
ii If my health changes such that I will answer Yes to any of the above questions in my Medical Self-
Declaration.
d. I will re-submit my Medical Self Health Declaration to reflect any change in medical status once it is
known to me.

Name: ____________________ Signature: ____________________ Date: ____________________

Part 2

Participants who are below 18 years old are required to have their parent/legal guardian complete this form.
Participants who are above 18 years old have to acknowledge by signing this indemnity form.

I, _________________________________ (Name of participant/parent/guardian, as applicable)
________________________________ (Passport or NRIC No.), *parent/guardian of
_________________________________ (Name of participant) ________________ (Passport or NRIC No.),
hereby declare that *I/my *child/ward *am/is participating in NUS BUSINESS ORIENTATION WEEK 2014,
4 8 AUGUST 2014 at *my/his/her own free will and volition, *am/is aware of the risks involved and in
consideration of being permitted by NUS STUDENTS' BUSINESS CLUB to participate in the Event, I, for
myself *and my *child/ward, my successors, personal representatives and assigns:

(a) do hereby absolve, acquit and discharge NUS and its officers, servants, employees, agents or
volunteers from all or any responsibility, actions, causes of action, claims, demands and obligations
whatsoever arising from any loss or damage (including, without limitation and to the extent permissible by
law, physical injury, loss of life or property damage) caused by or sustained as a result of *my/my
*child/wards participation in the Event; and

(b) will indemnify and keep indemnified, save and hold harmless NUS and its officers, servants,
employees, agents or volunteers against all losses, claims, demands, actions, proceedings, damages, costs or
expenses, including legal fees, and any other liability arising in any way from my/my *child/wards
participation in the Event.


_________________________________ ___________________________________
Signature Date

In the presence of:


_________________________________ ___________________________________
Signature of Witness Name & Passport/NRIC No. of Witness

*Please delete accordingly.


Health Declaration & Indemnity Form

3

Declaration of Swimming Ability


Participants who are below 18 on the date of the event are required to have their parent/legal guardian
complete this form.

I, _________________________________ (Name of participant/parent/guardian, as applicable)
________________________________ (Passport or NRIC No.), *parent/guardian of
_________________________________ (Name of participant) ________________ (Passport or NRIC No.),
hereby declare that *I/my *child/ward *am/is participating in the NUS BUSINESS ORIENTATION WEEK
2014, 4 8 AUGUST 2014, *I am/my child or ward is aware that the Event may involve activity conducted
in water or in the sea and *I am/my child or ward is able to swim continuously, without any floatation aid, for
at least 50m under 2 minutes.


_________________________________ ___________________________________
Signature Date

In the presence of:


_________________________________ ___________________________________
Signature of Witness Name & Passport/NRIC No. of Witness

*Please delete accordingly.