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DECLARATION All applicants in the list below agree abide by the rules and regulations stated and hold

themselves solely responsible for any mishap or injury that may occur during, or as a result of their participation, including rental of equipment from the outlet and of equipment from the outlet and certify that they do not have a pre-existing medical condition as declared below. (A copy of the Water-Venture Safety Guidelines is available at the counter) All applicants in the list below 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 their personal information to its employees, service providers, vendors and affiliated partners. 1) 2) 3) All users of equipments will have to fill up all details in this section Applicants are to fill up individual rental form with certification by Medical Examiner if any medical condition is ticked Applicants who are under 21 years of age are to indicate if they have obtained permission from their/ parents/guardian to use the equipments

I have obtained permission from my parent/guardian to use the equipment as I am under 21 years of age 1 HAVE YOU EVER HAD (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/poor vision (e) Ear problem/deafness (f) Nervous illness (g) Diabetes

Please tick if you have any of the condition stated

(b) Special diet 3 DO YOU HAVE (a) Any disability (b) Any other medical information to note, e.g. food, drug allergy

(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 (a) Routine medication

No.
1

Name

NRIC/PASSPORT No. Foreign I D No.

Date of Birth (DD/MM/YYYY)

Emergency Contact No.

Name / Relationship

Signature/Date

REMARKS (DETAILS FOR ANY MEDICAL CONDITIONS THAT IS TICKED ( A separate form with the certification of fitness should be filled if any of the conditions are ticked)