OM SPACE ACADEMY HEALTH DECLARATION FORM 健康申明书 Health Declaration Form "*" indicates required fields 学生个人资料 Student Personal Information全名 Full Name per IC/ID* First 电话号码 Phone Number*身份证号码 IC/ID No.* 年龄 Age* 18岁以上 Above age of 18 18岁以下 Under age of 18 健康申明书 Health Declaration Form健康申明书 Health Declaration Form*Health Declaration Form Kindly read and understand this declaration statement prior to signing it. You must complete this health declaration form to subscribe our online course(s), workshop(s), program(s) and/or any other products, services and/or packages provided by Om Space (“the Courses”). If you are a minor, you must have this declaration signed by your parents or legal guardian. The purpose of this Health Declaration is to ensure that you are medically fit to join any of our Courses. In any event that you were diagnosed physically and/or mentally unhealthy and/or unfit, it is advisable that you must seek medical assistance prior to participating the Courses and we shall request for a copy of the medical and/or specialist report prior to granting the permission for you to attend the Courses. I hereby declare and agree that on the day of signing of this declaration:- 1. I am physically and/or mentally sound and/or fit to attend the Courses; 2. I have not taken up any hazardous occupation neither I have suffered any illness / disease requiring treatment for more than one (1) week; 3. I will declare my mental and physical health situation immediately to Om Space if any of my mental and physical health issues were diagnosed after signing of this Health declaration; 4. I will not cause any violence, trouble and/or any form of chaos during the participation of the Courses; and 5. I shall withdraw or Om Space shall be authorized to withdraw and/or stop my participation in the Courses immediately if I were diagnosed as physically and/or mentally unfit and I understand that all fees and/or payment paid by me or my parents or my legal guardian (as the case maybe) shall not be refundable. I hereby understand and acknowledge that:- 1. In the event any unforeseeable situation or incident occurred during the Courses due to my unstable physical or mental state, I agree that Om Space has the right to refuse and/or deny my participation in the Courses; 2. Om Space will not and shall not guarantee any positive and success result from the Courses that I have attended and the result shall be depending on my own involvement, attitude, willingness to participate and other positive deeds that shall be maintained by myself during the participation during the Courses; 3. Om Space shall not be liable for any violence and/or trouble and/or chaos during the Courses that caused by unhealthy mental state of me and/or other participants. I declare that the information provided herein above is accurate and to the best of my knowledge. I agree to accept any responsibility for any omissions in disclosing my existing or past physical and/or mental health conditions. I further state that I have duly read and understand this Health Declaration Form and the consequences by accepting the same and agree to be bound by the terms herein. 是，我同意。 Yes, I am aware and agree.签名 Signature*家长/监护人 签名（若学生/客户是18岁以下）Parents / Legal Guardians' Signature (if student/client is under the age of 18)家长/监护人 姓名Parents / Legal Guardians' Name 家长/监护人 身份证号码Parents / Legal Guardians' IC/ID No. 家长/监护人 电话号码Parents / Legal Guardians' Phone Number Submission Date NameThis field is for validation purposes and should be left unchanged.