Public Benefit Organisation Exemption No 930 026 454 Nonprofit Registration Number 001-298 NPO

DATE: _________________ MEMBERS Full Name

VENUE: ___________________

LEADER: ____________________ Complete only if your telephone number and/ or email address if changed; or is not on the club database

Who to contact in case of emergency name and number

NON- MEMBERS Full Name Who to contact in case of emergency name and number Your telephone number / email address Y /N

Would you like to receive more information about the club? Please note that by inserting your name on this list you acknowledge that you have read and understood the indemnity printed on the reverse hereof and agree to be bound thereby.

WAIVER AND INDEMNITY

Whereas the BIRDLIFE PORT NATAL BIRD CLUB (hereinafter referred to as the Club) arranges outings for its members; and whereas these outings are led by a member; and whereas because of the very nature of these outings may cover rough terrain, and whereas the members participate in the activities of the Club voluntarily, and unconditionally accept that they do so at their own risk; NOW THEREFORE 1. I hereby waive any claim which I may have against the Club, its Committee and/or any members of the Club acting on the Club's authority or within the scope of their functions or authority as a result of my death and/ or for any personal injury or loss or damage to property arising directly or indirectly from any negligent or wilful act or omission relating to the activities of the Club as outlined in the preamble above and indemnify the club against any loss suffered by me in this regard. For the sake of convenience all of the aforesaid parties are hereinafter collectively referred to as "the Club". 2. I indemnify the Club against any claims arising by third parties including my dependants from my injury or death during the course of my participation in the Club's activities including claims arising from any negligent or wilful acts or omissions in the circumstances set out in paragraph 1 above. 3. I also indemnify the Club and its members and/or its representatives acting with the clubs authority or within the scope of their functions or authority against any loss, damage or injury which they may suffer or for which they may be held liable as a result of any willful or negligent act or omission on my part. 4. I declare that I am in good health, physically fit and capable of withstanding the nature of the activities, and that I have taken (or alternatively have personally decided to dispense with) full medical advice before undertaking the activities. 5. I do hereby declare that I am older than eighteen years of age; alternatively that if I am a minor this agreement is executed with the consent of my legal guardian.