Kallang YEC BGM Amazing Race 15 September 2013 INDEMNITY FORM

PART I - PERSONAL PARTICULARS OF APPLICANT

Full Name (as in Singapore Passport): NRIC/ Birth Certificate/ Citizenship Certificate No.: NRIC No: Race: Home Address: Contact Numbers: Email Address: Next of kin (In case of emergency): Medical history (if any): Drug Allergy (if any): Contact No.: (Next of kin) Food Restrictions (if any): (H) (O) (Pgr / Hp)* Passport No. Marital Status: Date of Birth: Passport Expiry Date: Religion: Gender: Male / Female* Age:

PART II - DECLARATION AND CONSENT BY APPLICANT

I, ___________________________ of NRIC No. ________________, declare that the information given in this application is true and correct. I have read through and fully understand the terms and conditions apply at the overleaf of the application. I do hereby acknowledge that, by participating in the Kallang YEC BGM Amazing Race, I am fully aware of the risks involved in this race and I will not hold Peoples Association, their appointed officials, staff and volunteers responsible or liable for any injury, loss of life, damage or loss of properties whatsoever which may arise out of and in any way, directly or otherwise, connected with my participation in this race, including travelling to and from the event. I understand that this waiver of claim includes any claims based on negligence, action or inaction on the part of any of the above parties. _______________________________________ Signature of Applicant/Passport Holder _____________________ Date

PART III - To be completed by parent/legal guardian of applicant below 21 years old.

I, ___________________________, holder of NRIC No. ________________, being the Parent/Legal Guardian*, do hereby consent my son / daughter / ward* to participate in the Kallang YEC BGM Amazing Race. I / my son / daughter / ward* declare that the information given in this application is true and correct. I / We have read through and fully understand the terms and conditions apply at the overleaf of the application. I / We am/are fully aware of the risks involved in this race and I/we will not hold Peoples Association, their appointed officials, staff and volunteers responsible or liable for any injury, loss of life, damage or loss of properties whatsoever which may arise out of and in any way, directly or otherwise, connected with his / her participation in this race, including travelling to and from the event. I / We understand that this waiver of claim includes any claims based on negligence, action or inaction on the part of any of the above parties. _______________________________________

____________________

Signature of Parent/Legal Guardian Date (To be signed by Parent/Legal Guardian if applicant is below 21 years old)
* Delete where applicable

FOR OFFICIAL USE

Handled By (Name of Staff): _____________________________________ Collection Date: ____________ _
Adult $10