COMMUNITY SERVICE ATTACHMENT

ACKNOWLEDGMENT OF RISKS & UNDERTAKING

To be completed and signed by PARTICIPANT OF AGE 21 AND ABOVE
To : Singapore Management University
Centre for Social Responsibility (C4SR)
School of Information Systems
80 Stamford Road #B1-65
Singapore 178902

Tel: (65) 6828 0796 / 0676

Fax: (65) 6808 5375
Email: commsvcs@smu.edu.sg

ACKNOWLEDGMENT OF RISKS & UNDERTAKING

I confirm that, where applicable, I have obtained all consents and approvals necessary from
(Organisation)
[insert name of the CSP organisation]

and other relevant organisations and authorities to carry out a community service attachment
(Attachment) in
[insert name of the community service attachment]

from the date of

[country of attachment]

to
[dd/mm/yy]

[dd/mm/yy]

(or any other dates that may be arranged by the Organisation or SMU).
I recognize and accept that my involvement in the Attachment involves certain amount of risks,
both foreseeable and unforeseeable (including but not limited to sustaining personal injuries and/or
loss of life). I undertake to cooperate fully with all rules and regulations of the Organisation, any
other relevant organisations and authorities, and SMU, including but not limited to safety
instructions. I confirm that I have fully informed my parents of my involvement in the Attachment.
I further undertake not to perform any illegal act or participate in any illegal activity, or conduct
myself in a manner that may tarnish the reputation of SMU. I agree to abide by the ground rules set
by SMU and the project leaders throughout the project, including not consuming alcohol during the
project. I am aware that I will be referred to the University Council of Student Conduct for
disciplinary actions if I am found to have broken any of the rules and regulations.
I hereby irrevocably undertake that I shall not, to the fullest extent permitted by the laws of
Singapore, hold SMU, its staff, officers, faculty, or any of its authorised agents responsible for any
damage to or loss of property or any injury or loss of life which may be sustained by me during the
Attachment or arising from any cause in connection with the Attachment where such damage to or
loss of property or any injury or loss of life is not caused by the negligence of SMU, its staff,
officers, faculty, or any of its authorised agents.

Matriculated Name of Participant

Participants Signature
(continue on next page)

Page 1 of 3

ver201409

a) Medical
I would like to take the opportunity to highlight that I have the following medical condition(s)
which is completely and accurately described below (e.g. allergies, impairment etc.):

Please indicate as NIL if not applicable

My blood type is:

b) Further Medical Precautions
I understand that I should make suitable enquiries closer to the start of the Attachment, of any
further recommended medical precautions I may need to take to ensure my health and safety during
the Attachment, including taking vaccinations.
I further understand and acknowledge the possibility of health risks associated with participating in
the Attachment.
c) Disclosure of Personal Information
I hereby give permission for my personal information set out herein to be shared with the student
leader/Organisation for the purposes of administrating and managing my participation in the
Attachment

Matriculated Name of Participant

Signature

*NRIC/ FIN No.

Year of Admission

Date

*Delete where not applicable

Page 2 of 3

ver201409

Receipt of Submission (Optional)

DO NOT PRINT UNLESS YOU REQUIRE THIS PAGE FROM C4SR
AS PROOF OF YOUR SUBMISSION
Optional: For a receipt of submission for your record, please:
fill in the details below
bring it along with the above form for acknowledgment
ACKNOWLEDGMENT OF RISKS & UNDERTAKING FORM

Receipt of Submission
has submitted the
[insert Matriculated Name, NRIC/ FIN No., Year of Admission]

Acknowledgement of Risk and Undertaking form to carry out the Attachment below:
(Attachment)
[insert name of the community service attachment]

from the date of

to
[dd/mm/yy]

(or any other dates that may be

[dd/mm/yy]

arranged by the Organisation or SMU), with

(Organisation)
[insert name of the CSP organisation]

and other relevant organisations and authorities.

C4SR Received stamp

& the Initial of C4SR officer

Page 3 of 3

ver201409