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Annex A

LETTER OF CONSENT BY PARENTS / GUARDIANS (for Adventure Training Camp at Changi Coast Adventure Centre) Dear Sir/Ma’am, 1. As part of National Civil Defence Cadet Corps (NCDCC) program, your child/ward is required to undergo a 2 day-1 Night Adventure Training Camp (ATC) at Changi Coast Adventure Centre. (From Saturday to Sunday, 12th February 2011 to 13 th February 2011). To build up their confidence and teamwork, they will be engaged in various activities such as Adventure Training Facilities (ATF) and Water bound activity. Apart from that, they will also be moulded into better leaders and team players. 2. Trainees would be briefed on all safety aspects before every activity to ensure an enjoyable and enriching session. Training would also be done in accordance to facility standard procedures and safety regulations. Trainees are not allowed to bring mobile phones or other valuables and food. 3. Please fill up the consent form below if you wish to allow/disallow your child/ward to participate in this enriching camp. 4.

If you have any queries please contact the following people:

NAME

APPOINTMENT

CONTACT NUMBER

A/MAJ (NCDCC) Tan Eng Wee

Head Training (Development)

63146714/ 98157534

CPT Lim Teck Leong

Head Training (Field)

63146715/ 98210560

LCP Muhammad Shadiq Bin Eksan

Assistant Field Instructor

64653879/ 91271385

6.

Thank You for your kind attention.

Yours faithfully, CPT (NCDCC) Tan Eng Wee Head Training (Development) National Civil Defence Cadet Corps Please detach this reply slip and return to NCDCC HQ REPLY SLIP 1. I, parent / guardian of ______________________________ of NRIC No. __________________ have read the letter above and I consent / do not consent to my child/ ward’s participation in the above mentioned Adventure Training Camp from 12th February 2011 to 13th February 2011 at Changi Coast Adventure Centre. 2. I confirm that all the medical declaration/information (Annex A) provided is true and that my child/ward is currently not suffering from any acute ailments and/or diseases. Name of parent/guardian:

Contact No:

Signature of parent/guardian

Date:


Annex A

SECTION 1 APPLICANT’S PARTICULARS – Organisation

: National Civil Defence Cadet Corps

School / Division

: __________________________________________________________

NRIC No

: __ - __ __ __ __ __ __ __ - __

Rank

: _____________________

Full Name

: __________________________________________________________

Gender

:M/F*

Date of Birth

: __ __ / __ __ / __ __ __ __

Race

: _____________________

Religion

: _____________________

Home Address

: __________________________________________________________

Postal Code

: Singapore __ __ __ __ __ __

Contacts

: __ - __ __ __ - __ __ __ __ (hm) , __ - __ __ __ - __ __ __ __ (hp)

E-mail Address

: ___________________________@_____________________________

Ability to Swim 50m with LifeVest

: Yes / No *

Outdoor Interests & Sports Indicate your involvement in the following by 0 = None 1 = Sometimes 2 = Frequently __ Swimming __ Kayaking

__ Running / Jogging __ Rock-Climbing

__ Camping

* – please circle where applicable SECTION 2 MEDICAL DECLARATION – Does the applicant have the following medical history (if yes, please describe) a.

Chest pain, High blood pressure, Heart problems

Yes / No


Annex A * Description: ________________________________________________ b.

Asthma, Bronchitis, Tuberculosis, Sinusitis, other Lung-related problems Description: ________________________________________________

Yes / No *

c.

Fits, Elipsy, Fainting attacks, Migraine, Severe head injury

Yes / No *

Description: ________________________________________________ d.

Eye problems, Poor vision

Yes / No *

Description: ________________________________________________ e.

Ear problems, deafness

Yes / No *

Description: ________________________________________________ f.

Nervous illness

Yes / No *

Description: ________________________________________________ g.

Diabetes

Yes / No *

Description: ________________________________________________ h.

Allergy to medicine / food / others

Yes / No *

Description: ________________________________________________ i.

Bone or joint injury

Yes / No *

Description: ________________________________________________ j.

A carrier status for any infectious disease

Yes / No *

Description: ________________________________________________ k.

Medical treatment within the last two years Description: ________________________________________________

Yes / No *


Annex A Does the participant require the following (if yes, please describe) l. Routine medication

Yes / No *

Description: ________________________________________________ m. Special diet

Yes / No *

Description: ________________________________________________

* – please circle where applicable SECTION 3 NEXT-OF-KIN’S PARTICULARS – NRIC No

: __ - __ __ __ __ __ __ __ - __

Full Name

: ___________________________________________________

Address (if different from above) Relationship (to Applicant) Contacts

____ : ___________________________________________________ ____ : ________________________ : __ - __ __ __ - __ __ __ __ (hm) , __ - __ __ __ - __ __ __ __ (hp)


ATC Consent Form