SPORTS ORIENTATION CAMP
4-6 December 2008 Singapore Polytechnic
Application Form
Please print your information clearly in BLOCK LETTERS. Personal Information Responsible Organization/School
Passport Size Color Photograph
Full Name as in Passport/NRIC
Nationality
Gender M Date of Birth (Date/Month /Year) /
F
Passport/NRIC No.
/
Home Address Postal Code Contact Mobile Number
Home
Email
Interest of Sports: Basketball Soccer Disability
Visually Impairment Hearing Impairment
Track & Field Boccia
Swimming Archery
Others, please specify: ________________
Celebral Palsy Les Auture
Intellectual Disability Physically Disabled (WC/Non-WC)
Amputee Others,Please Specify: __________________
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:____________________ Yes, Please Specify:____________________
Are you taking any medication? No
Special Needs Details Classification of mobility:
Able to move around with no walking aids
Need walking aids to move around
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 For School/Organisation only Name of Authorised Person: Designation: _________________________
_______________________________ Signature & Date
School / Organisation:
________________________
_________________________
Official Stamp & Signature:
Official Check List Registration Form Payment
Accept/Yes □ Complete □ Cash
FOR OFFICIAL USE Reject/No □ Incomplete □ Cheque (No: )
Remark (if any) Date Received: Date Received:
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: Male/Female Contact Details: (Next of Kin)
NRIC/ Passport No:
Next of Kin’s Name:
Relationship:
Tel: _______________ Off: _______________
Mobile: ________________ 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