RunNUS 2013 Health Declaration and Indemnity form This declaration form must be filled in and submitted by all

participants of RunNUS 2013.

1. Health Declaration: (* Delete where applicable) To be completed by participants (for above 21 years old as of registration) or Parents/Guardian (for below 21 years old as of registration) 1. Have you ever had Yes No If "Yes" Please Specify a) Chest pain, high blood pressure, heart problems such as heart murmur, extra heart beat or other heart abnormality? b) Asthma, bronchitis, tuberculosis, sinusitis, other lung problems? c) Fits, epilepsy, fainting attacks, migraine, severe head injury? d) Eye problem except short sightedness? e) Ear problem/deafness? f) Nervous illness? g) Bone or joint injury? h) A carrier status for any infectious disease? i) Medical treatment within last two years? j) Are your pregnant? 2. Do you have a) Any disability? b) Pacemaker? 3. Do you a) Require routine medication? b) Have any other medical information to note? e.g. food, drug allergy Medical Certification (To be completed by a Medical Examiner if "Yes" indicated for any condition listed in 1 and 2) I examined _________________________ on _______________ and found him or her FIT/UNFIT* to (Name of participant) (Date) participate in RunNUS 2013. Remarks: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

_________________________ Name of Medical Examiner

_____________________ Signature and Date

____________________ Clinic Stamp

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2. Only part 2a or 2b needs to be submitted. 2a. Indemnity for below 21 years old (* Delete where applicable) To be completed by Parent/Guardian I, __________________________________ (Name) ______________ (Passport or NRIC No.), *parent/guardian of _________________________________ (Name) ______________ (Passport or NRIC No.), hereby declare that my *child/ward is participating in RunNUS 2013 on 25 August 2013, on his/her own free will and volition, and are aware of the risks involved and in consideration of my *child/ward being permitted by NUS STUDENTS SPORTS CLUB, National University of Singapore (NUS) to participate in RunNUS 2013, I, for myself and my *child/ward, our successors, personal representatives and assigns: (a) do hereby absolve, acquit and discharge NUS and its officers, servants, employees, agents or volunteers from all or any responsibility, actions, causes of action, claims, demands and obligations whatsoever arising from any loss or damage (including, without limitation, physical injury, loss of life or property damage) caused by or sustained as a result of my *childs/wards participation in the Event; and (b) will indemnify and keep indemnified, save and hold harmless NUS and its officers, servants, employees, agents or volunteers against all losses, claims, demands, actions, proceedings, damages, costs or expenses, including legal fees, and any other liability arising in any way from my *childs/wards participation in the Event. (c) declare that my child/ward have no medical condition that would affect his/her safety and physical well being arising from his/her participation in this Event and that I am medically and physically fit and competent to participate in the Event. (d) The information provided in this form is accurate and filled in to the best of my knowledge
th

____________________________________ Signature of *Parent/Guardian

_________________________ Date

In the presence of: ____________________________________ Signature of Witness For Official Use only: Amount Paid: Race Bib Allocated: Date: Acknowledgement Slip Number: Name and Signature: _________________________ Name & Passport/NRIC No. of witness

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2. Only part 8a or 8b needs to be submitted. 2b. Indemnity for above 21 years old (* Delete where applicable) I, _________________________________ (Name) _______________ (Passport or NRIC No.), hereby declare that I am participating in RunNUS 2013 on 25th August 2013, on my own free will and volition, am aware of the risks involved and in consideration of being permitted by NUS STUDENTS SPORTS CLUB, National University of Singapore (NUS) to participate in the RunNUS 2013, I, for myself, my successors, personal representatives and assigns: (a) do hereby absolve, acquit and discharge NUS and its officers, servants, employees, agents or volunteers from all or any responsibility, actions, causes of action, claims, demands and obligations whatsoever arising from any loss or damage (including, without limitation, physical injury, loss of life or property damage) caused by or sustained as a result of my participation in the Event; and (b) will indemnify and keep indemnified, save and hold harmless NUS and its officers, servants, employees, agents or volunteers against all losses, claims, demands, actions, proceedings, damages, costs or expenses, including legal fees, and any other liability arising in any way from my participation in the Event. (c) declare that I have no medical condition that would affect my safety and physical well being arising from my participation in this Event and that I am medically and physically fit and competent to participate in the Event. (d) The information provided in this form is accurate and filled in to the best of my knowledge

_________________________________

_________________________

Signature Date In the presence of: _________________________________ Signature of Witness _________________________ Name & Passport/NRIC No. of Witness

For Official Use only: Amount Paid: Race Bib Allocated: Date: Acknowledgement Slip Number: Name and Signature:

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To know more about the Annual Giving Campaign, visit www.annualgiving.nus.edu.sg