FORM 3: APPOINTMENT OF LOCAL REPRESENTATIVE

Faculty/Department: Student No.:
Please tick one box only:
THIS MUST BE COMPLETED AND RETURNED TOGETHER WITH YOUR ACCEPTANCE FORM
(1) TO THE RELEVANT FACULTY/SCHOOL (FOR GRADUATE COURSEWORK PROGRAMMES); OR
(2) TO THE REGISTRAR’S OFFICE (FOR OTHER GRADUATE, NON-GRADUATING AND UNDERGRADUATE PROGRAMMES).
INTERNATIONAL STUDENTS BELOW 18 YEARS OF AGE ARE REQUIRED TO HAVE THEIR PARENT COMPLETE THIS FORM + .
FORM 3: APPOINTMENT OF LOCAL REPRESENTATIVE
[PLEASE REFER TO ATTACHMENT 1]
I hereby appoint the person named below as my local representative with the authority to authorise or refuse consent for any
surgery or other medical procedures or treatment on me/my child/my ward*, ____________________________________________,
on my behalf. (Name of Student)
In so doing, I, for myself and my child/my ward*, my successors, personal representatives and assigns, hereby agree that:
(a) I will not hold the University, its officers, any of its full-time or part-time staff (including student assistants), agents or
volunteers responsible or liable in any way for, and no right of action shall arise from, any loss or damage (including, without
limitation, personal injury, loss of life or property damage) caused by or sustained as a result of my local representative’s
authorisation or refusal of consent for any surgery or other medical procedures or treatment.
(b) I will indemnify and keep indemnified, save and hold harmless the University, its officers, any of its full-time or part-time staff
(including student assistants), agents or volunteers against all losses, claims, demands, actions, proceedings, damages,
costs or expenses, including legal fees, and any other liability arising from my local representative’s authorisation or refusal
of consent for any surgery or other medical procedures or treatment.
Particulars of Local Representative:
Name :
Passport/Identity Card No. :
Date of Birth :
Relationship to student :
Occupation
Telephone (Residence) : (Office) :
Telephone (Mobile) : (Fax) :
Email Address :
Postal Address :
I will not be appointing a local representative to authorise or refuse consent for any surgery or other medical procedures or
treatment on me/my child/my ward*, ___________________________________, on my behalf.
(Name of Student)
Signature of student/parent/guardian* :
Name :
Passport/Identity Card No. :
Relationship to student, if applicable :
Telephone (Residence) : (Office) :
Telephone (Mobile) : (Fax) :
Email Address :
Postal Address :
Date :
* Delete as applicable.
+
Where parents are deceased, a student below 18 years of age should provide the name of a legal guardian or any other person who has
legal authority over, and responsibility for, the student.

Attachment 1
APPOINTMENT OF LOCAL REPRESENTATIVE / AUTHORISATION OF MEDICAL
PROCEDURES FOR INTERNATIONAL STUDENTS
In the course of their studies in National University of Singapore (NUS), international students may
need medical attention in the form of surgery or any other medical procedures or treatment, but may
be unable to give or refuse consent to the same. In such an event, surgeons or consultants in
Singapore hospitals would require a local representative to be present at the hospital to authorise or
refuse consent to the surgery or other medical procedures or treatment on the patient’s behalf.
In order to avoid possible delays to any surgery or other medical procedures or treatment that an
international student may need, international students, or their parent/guardian (where the
international student is under 18 years of age), may do either or both of the following:
(a) Appoint a representative in Singapore (“Local Representative”) who will have the authority to
authorise or refuse consent to the surgery or other medical procedures or treatment, on behalf
of the student/parent/guardian, as applicable. This Local Representative should be informed of
his/her role by the student/parent/guardian and should be contactable by the student and/or
NUS at any time. Please complete Form 3 (Appointment of Local Representative) to indicate
whether a local representative is available.
AND/OR
(b) Authorise NUS, its officers, staff or any other authorised personnel to authorise or refuse
consent to the surgery or other medical procedures or treatment, on behalf of the
student/parent/guardian, if none of the student’s parent/guardian/Local Representative (if any)
is contactable at the time of need. Please complete Form 2 (Authorisation of Medical
Procedures For International Students) to indicate whether NUS is to be so authorised.
Notwithstanding the appointment and/or authorisation referred to in (a) and (b) above being
made/given, NUS will make every reasonable effort to contact the parent/guardian first if a student
needs medical attention as described above. If NUS is unable to contact the parent/guardian, NUS
will next contact the Local Representative (if any) and only when the Local Representative is not
contactable after reasonable efforts have been made will NUS, its officers, staff or any authorised
personnel authorise or refuse consent to the surgery or other medical procedures or treatment.
Please note that where an international student comes to Singapore alone and does not make the
appointment or give the authorisation referred to in (a) and (b) above respectively, there may be no
one present in Singapore who will have authority to authorise or refuse consent to surgery or other
medical procedures or treatment for that student in an emergency.
It is important that all international students wishing to accept NUS’ offer of admission have the
attached form(s) duly executed and returned to NUS together with their acceptance of NUS’ offer of
admission.
For the latest version of this policy, please refer to:
http://www.nus.edu.sg/osa/international/forms.html