KIDZ FOR CONSERVATION

INDEMNITY FORM

FULL NAME/NAMES OF CHILDREN--------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------

DATE OF BIRTH ---------------------------------------------------------------------------------------------------------------------------------

PARENT/GUARDIAN ---------------------------------------------------------------------------------------------------------------------------

CONTACT NUMBER 1 --------------------------------------------------------------------------------------------------------------------------

CONTACT NUMBER 2 ---------------------------------------------------------------------------------------------------------------------------

DOCTORS NAME AND CONTACT -------------------------------------------------------------------------------------------------------------

MEDICAL AID DETAILS --------------------------------------------------------------------------------------------------------------------------

ALLERGIES OR OTHER MEDICAL ISSUES ----------------------------------------------------------------------------------------------------

INDEMNITY:
PLEASE BE ADVISED THAT CHILDREN WHO ATTEND ECO CLUB WORKSHOPS ARE TO ABIDE BY ALL THE
INSTRUCTIONS
GIVEN AT ALL TIMES FOR THE SAFETY OF THEMSELVES AND OTHERS.
I HEREBY INDEMNIFY, THE LAWRENCE ANTHONY EARTH ORGANIZATION/KIDZ FOR CONSERVATION AND DEBBIE
BENNETT FROM ANY LOSS, DAMAGE AND/OR INJURY (FATAL OR OTHERWISE) OF WHATEVER NATURE THAT MAY
OCCUR WHILST ATTENDING MONTHLY WORKSHOPS FOR THE PERIOD OF JANUARY – DECEMBER 2019.

I HAVE READ AND UNDERSTOOD THE AGREEMENT FULLY, I SIGN THIS OF MY OWN FREE WILL.

SIGNED BY PARENT/GUARDIAN -----------------------------------------------------------------------------

DATE --------------------------------------------------------------