SPORTS ORIENTATION CAMP
4-6 December 2008
Singapore Polytechnic
Application Form
Please print your information clearly in BLOCK LETTERS.
Personal Information
Passport Size
Responsible Organization/School Color
Photograph
Full Name as in Passport/NRIC
Nationality Gender
M F
Passport/NRIC No. Date of Birth
(Date/Month /Year)
/ /
Home Address
Postal Code
Contact
Mobile Number Home
Email
Interest of Sports:
Basketball Track & Field Swimming Others, please specify: ________________
Soccer Boccia Archery
Disability
Visually Impairment Celebral Palsy Intellectual Disability Amputee
Physically Disabled Others,Please Specify:
Hearing Impairment Les Auture (WC/Non-WC)
__________________
The application form and payment must be submitted to SDSC not later than 17 October 2008.
Singapore Disability Sports Council, 230 Stadium Boulevard Singapore 397799
SPORTS ORIENTATION CAMP
4-6 December 2008
Singapore Polytechnic
Medical Details
Do you have any dietary requirements?
No Yes, Please Specify:____________________
Do you have any medical condition that we should be aware of?
No Yes, Please Specify:____________________
Are you taking any medication?
No Yes, Please Specify:____________________
Special Needs Details
Classification of mobility:
Able to move around with Need walking aids to move around
no walking aids Please Specify walking aids:____________________
Mobility/Special needs
Electronic wheelchair Manual Wheelchair Walking stick Hearing aids
Others, please specify: ________________
Any other particular attention:
No Yes, Please Specify:____________________
_______________________________________________________________________________________________
I certify that the above information is true and correct.
For Parent/Guardian only
_______________________________ _______________________________
Name of Parent/Guardian Signature & Date
For School/Organisation only
Name of _________________________ School / ________________________
Authorised Organisation:
Person:
Designation: _________________________ Official Stamp & Signature:
FOR OFFICIAL USE
Official Check List Accept/Yes Reject/No Remark (if any)
Registration Form □ Complete □ Incomplete Date Received:
Payment □ Cash □ Cheque Date Received:
(No: )
Checked and Signed by Finance Department
Singapore Disability Sports Council, 230 Stadium Boulevard Singapore 397799
SPORTS ORIENTATION CAMP
4-6 December 2008
Singapore Polytechnic
Indemnity Form
Please print your information clearly in BLOCK LETTERS.
Details of Participants & Next of Kin (In case of Emergency)
Name: Home Address:
Gender: NRIC/ Passport No: Next of Kin’s Name: Relationship:
Male/Female
Contact Details: Tel: _______________ Mobile: ________________
(Next of Kin)
Off: _______________ Fax: ________________
Email add: ________________________________
I, ______________________ (Full Name of Participant), ______________________ (NRIC/Passport No),
the undersigned, hereby agree to take part in the Sports Orientation Camp 2008. I therefore will not
take any legal actions and/or claims against the Organizing Committee, instructors/ volunteers and all
persons and/or agencies connected with this camp before, during and after the commencement of the
activities.
I also certify that all statements I have made are true and declare that I am fit to participate in the camp.
I agree that I have been given the opportunity to seek legal advice and/or have waived such right
before signing this document.
Signature: _____________________ Date: ____________________
For applicant aged 18 years and under, parent or guardian must sign on behalf of the applicant in
respect of the above agreement
Parent/Guardian’s Signature:
Name:
Contact: Date:
Singapore Disability Sports Council, 230 Stadium Boulevard Singapore 397799