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Individual Indemnity Form
Your Name
(required)
Your Surname
(required)
Gender
Male
Female
(required)
Date of Birth
(required)
Child Identity Number
(required)
Cell Number
(required)
Child's Email
(valid email required)
School/University
(required)
Parent/Legal Guardian Name
(required)
Residential Address
(required)
* Parent/Legal Guardian Phone
(required)
Parent/Legal Guardian Phone
(required)
Parent/Legal Guardian Email
(valid email required)
Invoice/Order Number
(required)
Where did you hear about MiFootprint
word of mouth
video
print
radio
schools
universities
email marketing
website
social networking (twitter, facebook)
outdoor marketing
(required)
Please note that we may contact you for information or promotional purposes
I * hereby acknowledge that the above information is correct. I * hereby appoint and authorise the Management and organisers of this event** to act in my place as guardian with full authority and consent to myself undergoing surgical and or other medical treatment. I* undertake to pay the cost of such treatment. I* fully understand and accept that all activities are undertaken at my own risk. I* voluntary assume the risk and am aware that being such type of event**(s) inherent dangers and certain elements of unpredictability can occur, be it concerts, travel, activities or any other aspects. I* agree to indemnify and keep indemnified MiFootprint (Pty) LTD from any claims whatsoever and agree that I* shall not hold MiFootprint (Pty) LTD, it’s owners, staff, management or any other person forming part of this group/event** in any way liable for any personal injuries (fatal or otherwise), mental anguish, or loss of any kind whatsoever or howsoever caused during the event**. And further agree that I* will abide to all instructions issued by the leadership/facilitators/marshal’s or manager(s) of this event. I* also agree to pay for all damages/repairs caused to the event** / items caused by negligence or ignorance. Definitions: I* meaning myself together with my heirs, guardians, executors and administrator, as well as any other person partaking in the event whether individually or as a group. Event** meaning; camp, event, tour, equipment, travelling between venues, and all items required in above mentioned activity. All events & activities offered by this event on or off route if needed from time to time. MiFootprint (Pty) LTD reserves the right to cancel or change any Event**
I* acknowledge and understand all that is mentioned in this indemnity and that all is at my own risk.
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