Jonginenge - Holiday Club / Surf Lessons Medical Information & Indemnity Form

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THIS FORM IS A CONSENT TO PARTICIPATE, RELEASE, WAIVER OF LIABILITY AND INDEMNITY AGREEMENT. (All questions need to be answered. Insert "not applicable" in any fields for which you do not have information) www.jonginenge.co.za email: jonginenge@gmail.com cell: 0833052590 CC. no: 2005/034556/23

Name of Child *

Surname of Child *

Date of Birth *

YYYY

Home Address: *

Medical Aid (If yes, fill in the details below as requested) *

Yes

Medical Aid Scheme: *

Medical Aid Number: *

Name and Surname of Principal Member: *

Doctor's Name: *

Doctor's contact number: *

Allergies or Medication (Any Medical Conditions we should be informed about?) Please note that those children who are allergic to bees must bring along an EpiPen or an antihistimine. *

Mom's name: *

Mom's contact details: *

Mom's email address *

Dad's name: *

Dad's contact details: *

Dad's email address *

Emergency Contact Name and Surname (In case of an emergency, if we cannot get hold of any parent, who would you prefer us to contact?) *

Emergency Contact number: *

Name and Surname of Parent/Guardian giving consent: *

DO YOU GRANT PERMISSION FOR YOUR CHILD TO ATTEND THE HOLIDAY ADVENTURE CLUB / SURF LESSONS WITH JONGINGENGE? By selecting YES, you agree that you are aware that there are risks, hazards and uncertainties connected with their participation in the excursion, and that you understand that precautions will be taken to ensure the safety of your child at all times. You believe that Jonginenge will exercise due care to ensure the safety of your child. You therefore will not hold Jonginenge or the facilitators in charge, responsible for any injury incurred by your child. *

Yes

Date that this Indemnity Form was completed. *

YYYY

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