Please photocopy and paste the following onto a word document, print it out and fill it up! [Adjust so that the words are aligned in the middle of the document) Pass it to me during the next training (:

NGEE ANN POLYTECHNIC

CCA SPORTS CLUBS

HEALTH DECLARATION FORM

(1) Personal Particulars

Name (in Full):

Gender:

Male / Female

Student Number :

Contact Number:

Name of CCA Club:

(2) Medical Information

Existing Medical Condition(s) : Yes/No

If yes, please list:

Any Drug Allergy: Yes/No

If yes, please list:

List all Medications you are taking regulary:

List History of past injuries eg. Dislocated shoulder

3. Parental Consent

I, ____________________________________ (Name), _________________________ (NRIC NO)

certify that the above information of my child are true and correct and that I do not permit / permit him/her to join the above listed

sports CCA Club in Ngee Ann Polytechnic.

Name of Parent/Guardian

Contact Number

Signature/Date

Submitted by Club Management Comm :

Staff Advisor's signature and date :

*Health Declaration Form is to be submitted to the Management Committee of the Sports CCA Club for endorsement by

the Staff Advisor Thanks guys!! Love, Aly.