NYC - YEP Leaders’ Training
A. Workshop dates (please indicate the Code)
B. Is your project supported by the National Youth Council?
C. Your YEP Location & Period
D. The organisation endorsing your YEP
E. Personal particulars
Name (As in passport and underline surname)
Nationality NRIC No
Please insert a recent
Gender Ethnic group Religion
Female / Male Please bring a photo on
the first day of the
course if you are unable
Date of Birth & Age Occupation & Name of Marital Status
to insert a photo here
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Contact number(s) Email address
Name of Next-of-kin &
Address of Next-of-kin
Contact No. of Next-of-kin Home Tel Handphone number
Have you led a team on overseas community projects before?
Details of Expedition Leader’s / Facilitator’s Experience
Dates & duration Your role in the Destination Nature of project Organised By
Do you have any existing medical condition or allergies? If yes, please list them all
Why do you want to lead a Youth Expedition Project?
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Please describe your upcoming project in Singapore (Home Run, a requirement from NYC)
(name of local voluntary welfare organisations (VWO), objectives of the project, the beneficiaries and the activities
you plan to do with them)
Please describe your upcoming overseas YEP
(Which country, dates & duration of the project, name of your overseas partner, objectives of the project, the
beneficiaries and the activities you plan to do with them)
Have you done a feasibility study of your project site?
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Notes to workshop participants
The workshop is conducted by the Blossom Training, and it includes a field trip to Pulau Ubin. Workshop
participants will spend one night at the villagers’ homes where living conditions are basic and without modern
amenities. The activities will be conducted both indoor and outdoor, and in all weather conditions. The activities
can be physically and mentally challenging.
In the event of an evacuation due to/related to a pre-existing medical condition, the cost of evacuation from the
island back to Singapore will not be covered by standard insurance packages (please check your own policies) or
Blossom Training. Standard insurance packages also do not pay for evacuations due to any medical condition
that is/is a result of/is a complication of infection with Human Immunodeficiency Virus (HIV), AIDS or AIDS-related
complications (ARC) and Veneral Disease.
If you have any pre-existing medical condition that might recur/make you susceptible to injury/illness during the
workshop, or if you know/should reasonably know that you have/have been exposed to HIV, AIDS, ARC and VD,
then you should see a doctor regarding your medical status, participation in the workshop and seek advice on
preventive measures. You are strongly advised to obtain additional insurance to cover emergency evacuation and
medical costs in such cases.
DECLARATION (To be signed by workshop participant)
I shall fully comply with the training conditions, guidelines and regulations as set out by Blossom Training.
ACKNOWLEDGEMENT OF RISKS
I am fully aware that my participation in the Workshop involves certain amount of risk. I acknowledge that I am
participating in the Workshop voluntarily and with knowledge of these risks. I hereby undertake that l shall not hold
Blossom Training in respect of any loss or damage or any injury, illness or loss of life which may be sustained by me
during the Workshop or arising from any cause in connection with the Workshop howsoever the same.
I further declare and confirm that I have read and fully understood all the sections in this registration form including the
preceding acknowledgement and undertaking and all the information provided herein is true.
Name of Workshop Participant Signature Date
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ACKNOWLEDGEMENT & CONSENT OF PARENT/GUARDIAN
(to be completed and signed by the Parent/Legal Guardian where the workshop participant is below the age of 21
*please delete where not applicable
I …………………………………………………….……….holder of *NRIC/Passport No:…………………………
allow my *child / ward (name)……………………………………………….…………………………
to attend the Workshop on these dates __________________________________________________________
I am aware that my child’s/ward’s participation in the Workshop involves certain amount of risks. I acknowledge that
l am allowing my child/ward to participate in the Workshop voluntarily and with knowledge of these risks. I
understand that he/she will have to co-operate fully with Blossom Training and comply with training conditions,
guidelines and regulations as set out by Blossom Training. I hereby undertake that l shall hold harmless Blossom
Training in respect of any loss or damage or any injury, illness or loss of life which may be sustained by my child/
ward and/or me arising from any cause in connection with the Workshop howsoever the same may be caused.
I fully declare and confirm that I have read and fully understood all the sections in this Declaration form and ensured
that my child/ward fully understands the same and that all the information provided herein are true and ratify the
Medical Declaration and Undertaking given by my *child/ward.
Name of *Parent/Guardian Signature Date
Please email the form to Jenny Ong before the workshop and bring the signed copy on the first day of the course
Mobile: 9878 7753
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