The Mountain Club of South Africa Founded 1891
Afdeling · Magaliesberg · Section Established 1968

P.O. Box 72522, Lynwoodridge, Pretoria, 0040

Tel: 083 845 1573. Email: admin@mag.mcsa.org.za

wwww. magaliesberg.mcsa.org.za

Indemnity form for members, prospective members and guests of the MCSA,  Magaliesberg Section and persons participating in activities organised by or on behalf of the MCSA Magaliesberg Section.

PART 1

I, the undersigned……………………………………………………………………………………………..(full names)

Residing at …………………………………………………………………………………………………(full residential address)

having been born on…………………………………………………….…………………………………….(full date of birth)

and duly assisted herein by my guardian if I am a minor, do hereby agree and undertake in favour of the Mountain Club of South Africa, its national, regional and local committees, members, servants and agents (herein referred to as “the club”) that:

  1. I am aware of the dangers of personal injury or death inherent in mountaineering, hiking, scrambling, bouldering, rock climbing and activities incidental thereto to which I may be exposed as a result of my participation in club activities and activities organised by or on behalf of the club and I understand and accept that my participation in any such activities is at my own risk for which I accept all responsibility.
  2. I, accordingly, hereby irrevocably waive, relinquish and abandon all claims of any nature whatsoever which I may have against the Club or any of its members, arising out of my participation in club activities and activities organised by or on behalf of the club, for loss or damage to property, personal injury or loss of life, howsoever caused and irrespective of whether the loss or damage occurred as a result of negligence.
  3. Should I be injured whilst participating in club activities or activities organised by or on behalf of the club, I hereby appoint and authorise the meet leader (or such other person who is co-ordinating the activity on behalf of the club) to consent to my undergoing surgical or other medical treatment which in the opinion of the attending medical practitioner is necessary.  I further undertake to pay the cost of such treatment.
  4. I agree that the terms and conditions contained herein will remain binding upon me, my heirs, executors, administrators and assigns.

SIGNED AT                                      ON THIS                       DAY OF                               20______

IN THE PRESENCE OF THE UNDERSIGNED WITNESSES (below)

Signature: _______________________.

PART 2

DULY ASSISTED / REPRESENTED * BY…………………………………………………………(FULL NAME) IN MY CAPACITY AS GUARDIAN OF THE ABOVE MENTIONED MINOR

  1. I confirm that the minor referred to in Part 1 hereof is participating in Club activities with my consent and that I am aware of the dangers of personal injury or death inherent in mountaineering, hiking, scrambling,  bouldering, rock climbing and activities incidental thereto to which the minor may be exposed as a result of his/her participation in club activities and activities organised by or on behalf of the club and I understand and accept that his/her participation in any such activities is at my own risk for which I accept all responsibility.
  2. I, accordingly, hereby irrevocably waive, relinquish and abandon all claims of any nature whatsoever which I may have against the Club or any of its members, arising out of the minor’s participation in club activities and activities organised by or on behalf of the club, for loss or damage to property, personal injury or loss of life, howsoever caused and irrespective of whether the loss or damage occurred as a result of negligence.
  3. Should the minor be injured whilst participating in club activities or activities organised by or on behalf of the club, I hereby appoint and authorise the meet leader (or such other person who is co-ordinating the activity on behalf of the club) to consent to the minor undergoing surgical or other medical treatment which in the opinion of the attending medical practitioner is necessary.  I further undertake to pay the cost of such treatment.
  4. I agree that the terms and conditions contained herein will remain binding upon me, my heirs, executors, administrators and assigns.

SIGNED AT                                                ON THIS                       DAY OF                    20______

IN THE PRESENCE OF THE UNDERSIGNED WITNESSES

GUARDIAN (signature): __________________________.

WITNESSSES:

Name: __________________________.    Signature: __________________________.

Name: __________________________.    Signature: __________________________.

Only Part 1 is to be completed if the members / guest / participant  is over 21 years of age.

*Note:

  1. Part 1 and Part 2 are to be completed where the member / guest / participant is between 7 and 21 years of age.
  2. Part 1 does not need to be signed where the guest / participant is less than 7 years of age.
  3. Where the guest / participant is less than 7 years of age the word “assisted” is to be deleted.
Download