PRESIDENT'S CHALLENGE Jointly Organised By:

CHARITY SPEED CLIMB

23rd May 2010

REGISTRATION FORM Registration Fees: S$10 per team

Part of the Registration Fees will be given donated to President's Challenge 2010 - as part of People's Association Pledge

CATEGORIES (as per calendar year) * Please tick on one (1) box only

Each Team can consist of 2 Female, 2 Males or 1 Female & 1 Male

10 - 18 Team 19 - 25 Team Open Team

FAMILY OF TWO (Immediate Family Members) GROs Team (PA GROs such as CCC, CCMC, YEC, IAEC, MAEC and others)

PERSONAL PARTICULARS ( to be completed fully in CAPITAL LETTERS )

Team Name: (Not more than two words)

* Organiser reserved the right to reject team names that carry vulgarities

Member 1 Member 2

Full Name Full Name

NRIC/Fin/Pp NRIC/Fin/Pp

Date of Birth dd mm yy Date of Birth dd mm yy

Race Sex * Female / Male Race Sex * Female / Male

Email Email

Contact Nos (Home / Mobile) Contact Nos (Home / Mobile)

SNCS Cert No. (Complusory for lead Climb) SNCS Cert No. (Complusory for lead Climb)

Emergency Contacts Emergency Contacts

Next of Kin Next of Kin

Relationship Relationship

Contact Nos (Home / Office) Contact Nos (Home / Office)

(Mobile) (Mobile)

DECLARATION
We agree to abide by the rules and regulations stated overleaf and hold ourselves solely responsible for any mishap or
injury that may occur during, or as a result of, our participation in the stated course or activity organised by, including
rental of equipment from the outlet, and certify that I do not have a pre-existing medication condition as declared overleaf.

We hereby declare that all information provided is true and correct; and agree to abide and be bound by the Terms and
Conditions of the Community Club Management Committees, other People's Association Organizations; and authorize
the People's Association to disclose my personal information to its employees, service providers, vendors and affiliated partners.

Signature of Member 1 Signature of Member 2 Date

Consent of Parent/Guardian for Applicants below 21 years old

I, *Dr/Mr/Mrs/Mdm/Miss (Name) I, *Dr/Mr/Mrs/Mdm/Miss (Name)

(Nric No.) allow my *child/ward to (Nric No.) allow my *child/Ward to

participate in the competition under the conditions as mentioned above. participate in the competition under the conditions as mentioned above.

Signature of Parent/Guardian of Member 1 Date Signature of Parent/Guardian of Member 2 Date

*Delete as necessary PA/SS/03/2005
 IMPORTANT RULES AND REGULATIONS
1) All participants must satisfy the criteria for the chosen category. Participant is allowed to participate in more than one category.
2) Completed forms must be accompanied with payment. Registration closes on 16 May 2010, 4pm
3) Full payment must be paid either in cash, cheque or NETS, before the closing date. Cheques are to be made payable to
"PA Water-Venture".
4) There will be no refund for withdrawal from the competition.
5) Participants are required to wear proper climbing attire during climbing attempt and prize presentation.
6) Competition Bibs will be issue to second climber in the team on event day. Unreturned bibs cost $5.
7) Medals/Tropies will be award to the top 3 winners of each category.
8) In the event of minimal participation for any of the categories, Water-Venture reserves the right to
remove the category and refund the participants accordingly.
9) Water-Venture will not be held responsible or liable for any mishap or injury that may occur during the competition.
10) All appeal shall be written in English accompanied by a fee of S$50 which will be returned if successful.
11) Participants must complete the Medical Declaration, and a Certification of Fitness is required from a Medical Examiner
if a "Yes" is indicated.
12) Water-Venture reserves the right to cancel, postpone, or change the venue of competition without assigning reasons.

Member 1 - Medical Declaration (to be completed by Applicant or Medical Examiner if "Yes" is indicated)
1 HAVE YOU EVER HAD YES NO If "Yes," please give details
(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) Severe eye problems/poor vision
(e) Ear problems/deafness
(f) Nervous illness
(g) Diabetes
(h) Bone or joint injury
(i) A carrier status for any infectious disease
(j) Medical treatment within last two years
(k) Are you pregnant?
2 DO YOU REQUIRE YES NO If "Yes," please give details
(a) Routine medication
(b) Special diet
3 DO YOU HAVE YES NO If "Yes," please give details
(a) Any disability
(b) Any other medical information to note, e.g. food, drug allergy
CERTIFICATION OF FITNESS
(to be completed by Medical Examiner if "Yes" indicated for any condition above)

I examined on and found her/him FIT/UNFIT to participate

(name) (date)
in the competition

Remarks, if any

Name of Medical Examiner Signature and Date Clinic Stamp

Member 2 - Medical Declaration (to be completed by Applicant or Medical Examiner if "Yes" is indicated)
1 HAVE YOU EVER HAD YES NO If "Yes," please give details
(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) Severe eye problems/poor vision
(e) Ear problems/deafness
(f) Nervous illness
(g) Diabetes
(h) Bone or joint injury
(i) A carrier status for any infectious disease
(j) Medical treatment within last two years
(k) Are you pregnant?
2 DO YOU REQUIRE YES NO If "Yes," please give details
(a) Routine medication
(b) Special diet
3 DO YOU HAVE YES NO If "Yes," please give details
(a) Any disability
(b) Any other medical information to note, e.g. food, drug allergy
CERTIFICATION OF FITNESS
(to be completed by Medical Examiner if "Yes" indicated for any condition above)

I examined on and found her/him FIT/UNFIT to participate

(name) (date)
in the competition.

Remarks, if any

Name of Medical Examiner Signature and Date Clinic Stamp