TEMASE BS pOLYTECHIN Consent Form Please submit this form at ieast 3 days before the activity. K 1c Name of Activity BIT Interest Group In-campus Camp Duration 18th 7 March 72010 to 20th 7 March __/ 2010 Venue! Location’ ‘TEMASEK BUSINESS SCHOOL Name of OIC : _Jackson Na (IG Advisor)__ Tel/Hp :__67805402 Participant's Particulars | Full Name NRIC/Passport No. | Nationality Staff No./Adm No./Alumni No.. Age Gender : Male/Female Tel/Hp TTT) TTT ] sia est TTT TTT TE TT TT TTT Tit) |, hereby, undertake to indemnify Temasek Polytechnic against all claims arising out of any eat, injury, damage, loss suffered or caused in the course of participation in the above event, including all costs and expenses incurred as a result of such claims. Participant's Signature Date Parent’s/Guardian’s Consent (for participants below the age of 21) 1 NRIC/Passport No. am the “parent / guardian of the above-named participant. | hereby * do /do not consent to my *son’s / daughter's / ward's participation in the above activity. | also hereby to undertake on behalf of my “son / daughter / ward to indemnify Temasek Polytechnic against all claims | arising our of any death, injury, damage, loss suffered or caused in the course of participating | in the above activity, where such damage to or loss of property or any injury or loss of life is not caused by the negligence or willful act or omission of the Temasek Polytechnic or their ‘servants and agents. | further declare and confirm that all the information provided herein are true and ratify the | Medical Declaration and Undertaking given by my child/ ward. Parent's/Guardian's Signature Date | roto where applicable | In case of an emergency Contact Person : Mr /Ms Relationship Home Tel. Office Tel Hp ent TTT {TET TTI ITT ITT OIC: Overall-in-Charge of Off-campus activity EFOR-04-02.03 Consent Form 01/2004