YOUTH EXPEDITION PROJECT MEDICAL & DECLARATION

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Scarlett Howard
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YOUTH EXPEDITION PROJECT MEDICAL & DECLARATION INFORMATION FOR APPLICANT 1. Medical Examination We are pleased that you have enrolled in the YEP.

1 YOUTH EXPEDITION PROJECT MEDICAL & DECLARATION INFORMATION FOR APPLICANT 1. Medical Examination We are pleased that you have enrolled in the YEP. During the course of the programme, you will have opportunities to engage in exciting activities in a country in the ASEAN, China, India or Sri Lanka region. Some of the project sites may be located some distance away from professional medical support than we are used to in Singapore. Some of the activities may be strenuous and may take a physical toll on the body and mind. It is therefore important that you undergo a medical examination before signing up for the course. Please bring this form to a registered medical practitioner (preferably your regular/family doctor who knows you better than any other doctor). Parts 1 and 2 must be completed at the medical examination. An applicant will only be accepted to avail the YEP funding after being certified medically fit for the programme. The cost of this medical examination can be computed as part of the overall costing submission. Please submit your completed medical form to your Expedition Leaders. 2. Validity Period for Medical Examination This medical examination lasts for two years and it should cover the whole period of the expedition. If you are interested in leading another expedition within two years of the date of the medical examination, this form will still be valid. Please keep a copy of it to expedite you own application in the future. For leaders or self-paying return participants who have already completed a medical declaration and examination in the last two years, please fill in Part Do it immediately! This examination should be the first activity you do after your application to participate in an expedition is approved by the leader. This will certify that you are also physically able to cope with the expedition and do not put yourself or to the team at risk. We have had sad instances of participants who have procrastinated taking their medical examinations up to the very last minute only to face a disappointment that they were physiologically not ready for an expedition; this was after many months of being involved in expedition preparation with the team. Please see your doctor early! 4. We wish you an enjoyable and fruitful expedition preparation! The YEP Team National Youth Council Correct as on 3 Aug 2007 Page 1 of 5

2 YOUTH EXPEDITION PROJECT MEDICAL & DECLARATION FORM Name: NRIC: AGE: Project ID Expedition Country: MEDICAL HISTORY To be completed by Medical Examiner Notes for Medical Examiner : The person you are about to examine is applying to be a member of an overseas expedition organised by. o The expedition is supported by the National Youth Council (NYC) under the Youth Expedition Project (YEP). Expeditions under the YEP scheme range from days. o Approximately 50% of the expedition duration comprises physical community service projects like building small classrooms. The remainder of the duration could comprise capacity building, knowledge sharing, socio-cultural understanding and learning activities. o YEP expeditions are conducted outdoors in all weather conditions and involve participants in many hours of activities which can be both physically and mentally challenging. o There will be at least one member trained in basic first aid. o In most expeditions, quick access to basic and advance life support systems is unlikely and access to professional medical care may be delayed (generally up to two hours).. o YEP expeditions have 24 hour telephone access to a doctor of a commercial medical evacuation provider (International SOS) through their insurance provider. Please make particular note of any history of bone or joint injury and assess carefully the risk of further injury arising from participating in the YEP. Applicants with any of the following medical conditions are strongly discouraged from going on a YEP project. 1. Severe Obesity Based on the guidelines of Weight for Height Percentile Chart from MOH 2. Hypertension On long term medication which may have side effects likely to affect participation and/or with poor control of blood pressure 3. Anaemia Hb below 11gm%, uncorrected within one month of participation 4. Epilepsy Any attack within the last 3 years or on medication which have side effects likely to affect participation 5. Asthma Exercise-induced or requires frequent medical treatment from doctor, any attack requiring hospitalisation within one year of participation 6. Thalassaemia Major 7. Severe Allergy Grass, sea water, dust and insects 8. Any other Physical or Mental Disability that may affect his/her participation on the YEP expedition. 9. Recurrent Dislocation of Shoulder requiring medical treatment each time 10. Any cardiac/heart condition that is likely to affect participation, e.g. Mitral Valve Prolapse With significant regurgitation; arrythmia or conduction disorders. 11. Diabetes mellitus that is not well controlled (HbA1C > 7%) 12. Autoimmune disease that require long-term medications 13. Any condition or long-term use of medication that can result in an immuno-compromised state. 14. Severe backache problem requiring frequent medical attention. Please complete the CERTIFICATION OF FITNESS form based on the applicant s likely ability to cope in an expedition situation. You should not hesitate to assess as unfit, an applicant considered unlikely to cope with the expedition. Doctor s Initials: Correct as on 3 Aug 2007 Page 2 of 5

3 DECLARATION (To be signed by participant) UNDERTAKING The information provided is true to the best of my knowledge and I did not withhold any vital information. I shall fully comply with the training conditions, guidelines and regulations as set out by the expedition organisers and leaders. ACKNOWLEDGEMENT OF RISKS I am fully aware that my participation in the youth expedition project involves certain amount of risk. I acknowledge that I am participating in the youth expedition project voluntarily and with knowledge of these risks. I hereby undertake that l shall not hold the organisers, their sponsors (including without limitation the National Youth Council) and their respective officers, representatives, employees, volunteers and agents in respect of any loss or damage or any injury, illness or loss of life which may be sustained by me during the YEP or arising from any cause in connection with the YEP howsoever the same may by caused. I further declare and confirm that I have read and fully understood all the sections in this registration form including the preceding acknowledgement and undertaking and all the information provided herein are is true. Name & I/C No. of Participant Signature Date ACKNOWLEDGEMENT & CONSENT OF PARENT/GUARDIAN (to be completed and signed by the Parent/Legal Guardian where the participant is below the age of 21 years) *please delete where not applicable I,.. holder of *NRIC/Passport No:.. allow my *child / ward (name & I/C No.)... to attend the NYC-Youth Expedition Project from the date of. to I am aware that my *child s /ward s participation in the youth expedition project involves certain amount of risks. I acknowledge that l am allowing my *child /ward to participate in the youth expedition project voluntarily and with knowledge of these risks. I understand that *he /she will have to co-operate fully with the organisers and leaders of the expedition and comply with training conditions, guidelines and regulations as set out by the expedition organisers and leaders. I hereby undertake that l shall hold harmless the organisers, their sponsors (including without limitation the National Youth Council) and their respective officers, representatives, employees, volunteers and agents in respect of any loss or damage or any injury, illness or loss of life which may be sustained by my child/ ward and/ or me arising from any cause in connection with the YEP howsoever the same may be caused. I fully declare and confirm that I have read and fully understood all the sections in this YEP Medical and Declaration form including the preceding acknowledgements and undertakings and ensured that my *child/ ward fully understands the same and that all the information provided herein are true and ratify the Medical Declaration and Undertaking given by my *child / ward. Signature Date * please delete as appropriate Correct as on 3 Aug 2007 Page 3 of 5

4 PART 1: MEDICAL HISTORY (to be completed by Medical Examiner and/or Applicant) Height: Weight: Blood Grp: (Compulsory) Date of last Tetanus Immunisation.. 1. IS THERE A HISTORY OF/HAVE YOU EVER HAD a. Chest pain, High blood pressure, heart problems. E.g. 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 problems/poor vision NO YES If YES, please describe e. Ear problems/deafness f. Nervous illness g. Diabetes h. Allergy to medicines/food/others i. Bone or joint injury j. A carrier status for any infectious disease? k. Medical treatment within last two years 2. IS THERE A NEED FOR/DO YOU REQUIRE a. Routine Medication b. Special diet 3. IS THERE / DO YOU HAVE a. Any disability/disabilities or chronic medical ailment which may affect participation on the expedition b. Any other medical information to note MEDICAL DECLARATION (1) I declare that all the medical information provided above is true. Name of Participant Signature Date *(2) I declare that all the medical information provided above is true. Name of **Parent/Guardian Signature Date * to be completed by parent or legal guardian of participant under 21 years ** please delete as appropriate Doctor s Initials: Correct as on 3 Aug 2007 Page 4 of 5

5 PART 2: CERTIFICATION OF FITNESS (to be completed by Medical Examiner) CERTIFICATION OF FITNESS (*please delete where not applicable) I have this date....examined...(applicant s name) and found *him / her *FIT / UNFIT to participate in an expedition under the Youth Expedition Project Remarks : (if any) Name of Doctor.. Signature... Clinic Stamp Date... Notes for Participants: In the event of an evacuation due or related to a pre-existing medical condition contracted 12 months before the commencement of the expedition, the cost of evacuation will not be covered by standard insurance packages (please check your own policies) or NYC-YEP. Standard insurance packages also do not pay for evacuations due to any medical condition that is, or is a result of or is a complication of infection with Human Immunodeficiency Virus (HIV), AIDS or AIDS-related complications (ARC) and Venereal Disease. If you have any pre-existing medical condition that might recur or make you susceptible to injury or illness, or if you know or should reasonably know that you have or have been exposed to HIV, AIDS, ARC and VD, then you should see a doctor regarding your medical status, participation and preventive measures. You are strongly advised to obtain additional insurance to cover emergency evacuation and medical costs. Part 3: Use of Medical Examination results from a previous expedition (to be completed by Applicant (for an applicant who is below the age of 21, the declaration must be signed by the Parent/Guardian) *I /My child /My ward underwent a medical examination on at (clinic) for the expedition to from to and (destination) was certified fit by. The medical examination is within two years to (name of Medical Examiner) the return date of the forthcoming expedition to from (destination) to which *I / my child / my ward *am/is currently applying. I declare that *I /my child /my ward *have/has not contracted any illness, disease or injury since the said medical examination. Name of *Applicant / Parent or Guardian Signature Date * please delete as appropriate # Participants are advised to keep a copy of this form to facilitate participation in overseas expeditions within the next two years. Correct as on 3 Aug 2007 Page 5 of 5

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