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DSD-FRM-935

Indemnity Form

Release 1.0



INDEMNITY FORM

I wish to join the ______________________ (trip/activity/camp) organised by ___________________
from _________________ to _________________ and abide by the Rules and Regulations set by both
the Singapore Polytechnic and the Event Organising Committee. I am fully aware of the possible risks
involved and accept the same, notwithstanding the fact that this trip/activity/camp is intended only for
those without medical problems and who are fit enough to indulge in physical activities. I confirm that
I am enrolling on my own volition and I shall not hold the Singapore Polytechnic, its servants and
organisers responsible or in any way liable for my death, injury, disability or any loss or damage
whatsoever arising from any cause in connection with the trip/activity/camp or my participation therein.

I hereby indemnify and agree to keep the Singapore Polytechnic, its management, servants and
organisers of the event fully indemnified against all claims, loss or damage whatsoever in respect of
death, injury, disability or any loss or damage whatsoever arising from any cause in connection with the
trip/activity/camp or my participation therein.

Personal Particulars

Name : Gender* : Male / Female

Address :

Adm No : Course/Class: __________________ NRIC no. :

Email : Date of Birth :

Home No : Handphone No:


_______________________


__________________
Signature Date
..
Parents/Guardians Consent for Participant below 21 years of age on date of the Enrolment

I consent to the above applicant, who is my child/ward* participating in the above trip/activity/camp
and accept all legal and other responsibilities connected with the trip/activity/camp, as outlined above.

I hereby indemnify and agree to keep the Singapore Polytechnic, its management, servants and
organisers of the event fully indemnified against all claims, loss or damage whatsoever in respect of my
childs/wards death, injury, disability or any loss or damage whatsoever arising from any cause in
connection with the trip/activity/camp or his/her participation therein.


__________________________________ _____________________
Full Name of Parent/ Guardian* Signature

______________________ ______________________________ _______________
NRIC/Passport* No Contact No. (in case of emergencies) Date
* Please delete accordingly