OVERSEAS TRIP
APPLICATION FORM FOR PARTICIPANT
ADVENTURE CAMP - MAWAI LAMA 2008
10-12 JUNE 2008
SUBSIDIZED COST: $100 PER STUDENT
APPLICANT’S PARTICULARS ( Part A )
Name (As in passport and underline surname):
Alias/ Chinese Character
Nationality
(Please indicate if you are a Singapore PR):
NRIC/ Passport No:
Place of Issue
Date of Issue:
Date of Expiry:
Student No:
Course/ Level:
Module/ Mentor Group:
Sex:
Race:
Date of Birth:
Affix Recent Passport
Size Photograph Here
Marital Status:
Age:
Religion:
Blood Type:
Home Address:
T-shirt Size:
E-mail:
Home Tel No:
Pager/ Handphone:
Name of Next of Kin (NOK)
Relationship to Applicant:
NOK Contact No:
Office/ Handphone/ Pager/ E-mail
Swimming Ability:
Good/ Average/ Poor
Medical History (Circle where necessary)
Heart Problem / Fits / Fainting Spell / Diabetes / Asthma / Migraine / Vision Problem / Colour Blind / Ear problem /
Fractures / Dislocations / Carrier Status / None
Current Medication:
Dietary Requirements/ Food Restrictions:
None / Vegetarian / Halal / No Seafood
Other Medical/ Physical Conditions/ Allergies:
Adventure Camp – Mawai Lama 2008
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ACADEMIC/ ECA (Part B)
Past ECA records
ECA In NgeeAnn Polytechnic
Have you attended any overseas programme with NP?
YES / NO
If YES, please specify: (Programme and country)
In what capacity:
If Others, please specify:
Participant / Students Leader / Others
When are you having IAP / IHP?
________ yr
May / Nov (Period) /
Completed
FAMILY DETAILS (Part C)
Relationship
Father
Name
Age
Occupation
Monthly Income
Mother
Self
Brother / Sister *
Brother / Sister *
Brother / Sister *
Others
Total
* Circle whichever applicable
Please provide information on a separate sheet of paper if necessary.
TYPE OF RESIDENCE (Part D)
Private housing
Rented
Condominium
Owned occupied
Terrace
Semi-detached/ Bungalow
Public housing
Rented
2 room flat
Owner occupied
3 to 4 room flat
5 room flat
Executive flat
Adventure Camp – Mawai Lama 2008
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I agree to:
a) Abide by all rules stated in the safety guidelines and trip pamphlet.
b) Follow all instructions given by any of the staff-in-charge, local guides/ instructors, park rangers, or any
appointed personnel on duty during the trip.
c) Declare all necessary information regarding my personal health and skills to the staff-in-charge before or
during the trip.
d) Be responsible for my personal safety at all times throughout the trip.
e) Pay NgeeAnn Polytechnic the FULL cancellation charges and expenses incurred if participants withdraws or
fails to show up for the trip.
________________________
Name/ Signature: Applicant
_______________________________
_______________
Name/ Signature: Parents/ Guardian
Date
(If participant is below 21 years old)
----------------------------------------------------------------------------------------------------------------------------- ----------------------------------
INDEMNITY FORM (Part F)
PART 1 – To be completed by parent/ guardian of participant below 21 years old
I, (name) ____________________________, (NRIC/ passport No.) __________________________ being the
(relationship) ______________________ of (Name of Applicant) ____________________________ agree to allow
my son/ daughter/ ward* to participate in ____________________________________________________________
_______________________________________________ organised by NgeeAnn Polytechnic.
Part 2 – To be completed by participant 21 years old and above, OR parent/ guardian of participant below 21
years old
I, (name) ____________________________, (NRIC/ passport No _______________________ agree that I shall not
hold the responsible for any mishaps, injury or loss of life that may occur in the course of, or as a result of my/ my
child’s/ my ward’s participation in
Programme/ Trip:
I shall also indemnify NgeeAnn Polytechnic, the participating organisations i.e. the host, and/ or their and their staff
against any claim by any party for damages or compensation whatsoever in the event of any injury or death by
myself/ my child/ my ward named above.
_____________________
Signature & date
Adventure Camp – Mawai Lama 2008
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