FDA-ELP (3 Parts) Declaration

Only FDA-ELP Course registrants need to fill this.

Please indicate whether you have any of these illnesses and conditions. Fill in as accurately as possible.

Particulars

Full Name (as in NRIC)(required)

NRIC(required)

Gender(required)

Date of Birth(required)

Home Address(required)

Phone(required)

Email(required)

Emergency Contact Person

Name(required)

Phone(required)

Medical History

1. Frequent headaches / dizziness / fainting spells.(required)

2. Asthma (uncontrolled)(required)

3. Tuberculosis (TB)(required)

4. Hepatitis A/B/C(required)

5. AIDS/HIV(required)

6. Eye problems/poor vision(required)

Others, if any:

By submitting this form, I hereby declare that all the information provided is true and accurate to the best of my knowledge and I have not deliberately omitted any relevant fact(s). Should I be admitted to 4Hands Dental Assisting Training School Pte. Ltd. on the basis of the information given in this form which may later turn out to be false or inaccurate, I understand that I will render myself liable to appropriate disciplinary action, including dismissal from the course.