GSWP Adult Indeminty Form

PLEASE NOTE THAT NO PERSON MAY PARTICIPATE IN ANY GSWP OR SA SCHOOLS EVENT UNLESS THE INDEMNITY FORM IS COMPLETED AND SIGNED.

I,___________ __________________________________ [Full name and surname], being of legal age, hereby give consent to participate in the sporting activities of Gauteng Schools Water Polo and SA Schools Water Polo ("the Club"), and to go on approved Club tours and excursions related to such sporting activities.

I hereby indemnify and hold the Club, its agents, representatives, coaches and managers harmless against any claim or demand arising from the death of, or injury to, myself or any loss of or damage to property, financial status, of whatsoever nature and howsoever sustained, including consequential loss, arising from or occasioned by my participation, in any such sporting activities and/or such tours and excursions.

I agree that, if in the opinion of the Chairperson of the Club or his delegated deputy, an emergency has arisen and medical treatment be deemed necessary for myself, the Chairperson of the Club or his delegated deputy shall have the authority (which is hereby delegated to the extent such delegation may be required) to consent to such medical treatment, including surgical intervention, on my behalf.

I accept that reasonable precautions will be taken to ensure my safety and welfare and that I will be held responsible for the payment of medical and/or hospital accounts where applicable.

As far as I am aware I am physically capable of participating in the said sporting activity and I am good health.

Please state aspects that the staff should be aware of, e.g. allergies, tendency towards abnormal bleeding, epilepsy, diabetes, recent injury, relevant surgery, routine medication, etc.
Please note the following information:

___________________________________________________________________

___________________________________________________________________

Participants Age: ____________________________
Participants Cell: ____________________________
Participants Tel: ______________________________
Participants Banking Acc No: _____________________
Bank name:_______________________
BC:__________________________
Type of account: _______________________________
Bank tel: _________________________

The following information is essential in case of medical treatment or hospitalisation:

PERSON TO CONTACT IN CASE OF AN EMERGENCY:
Name___________________________________
Cell: ___________________________________
tel. W
tel. H
PARTICIPANTS EMPLOYER:
Name: _________________________
address: _________________________________
tel.

PARTICIPANTS MEDICAL AID FUND:
Name: _________________________
Membership No: ___________________________
tel.
PARTICIPANTS FAMILY DOCTOR:
Name: _________________________
tel. W:__________________________
tel. H:__________________________

SIGNATURE OF PARTICIPANT / GUARDIAN:_______________
DATE:____________ I.D. NUMBER: ________________________________
PLACE:____________

SIGNATURE OF WITNESS:___________________
DATE:____________ I.D. NUMBER: _______________________________ PLACE