CLUB Elani – Misverstand Dam FUN RIDE - REGISTRATION FORM

SATURDAY, 27 August 16 - QuadBikes / 2 Wheeler (Off-Road)

Please complete the following:

RIDER DETAILS
Name & Surname of rider: / Riding a: / Age: / Male/Female
1.
Email address:
Child Details
Name & Surname of Child: / Riding with / Age: / Male/Female
1.

And if applicable, lift details:-

LIFT DETAILS
Name & Surname of lift: / Riding with / Age: / Male/Female
1.
Kindly provide at least one person from the group’s contact details: / Kindly provide contact details, in case of an emergency eg. relative:
Name & Surname: / Name & Surname:
Cell No: / Cell No:

WHEREAS. I ______(full name / Surname)An adult together with my wife and children or other passengers. Will willingly be participating in CLUB Elani – Misverstand Dam FUN RIDE I acknowledge that in participating in these activities I shall be subjecting myself, family and passengers and my vehicle/quad bike/ 2 wheeler or side by side, to danger and the possibility of personal injury, loss of support and / or the loss of my life or family or passengers lives, and / or the loss or damage to personal possessions during this event and date of event..

THEREFORE, I ______full name) in my personal capacity as well as natural guardian of my minor childrendo hereby acknowledge that I have freely and voluntarily accepted fully the risk, to myself and my minor dependents and do hereby on behalf of myself, my heirs, executors, administrators or assigns or assigns forever discharge, release and indemnify, hold harmless and absolve the organizers of theCLUB Elani – Misverstand Dam FUN RIDE, their committee, land owners and any other person Involved in the above activities even where such activities constitute a negligent act or omission on the part of the CLUB Elani – Misverstand Dam FUN RIDE from any claim or claims of whatsoever nature prior to an including the date/s of the activities and particularly as a result of any activity of whatsoever nature in which the Fun Day is in any way party to. I acknowledge the Rules of CLUB Elani – Misverstand Dam FUN RIDE And I do further indemnify the Fun Day against any claim or claims, which may be brought against them by anyother person or body arising out of my actions aforementioned, and In particular against claims made against the Fun day CLUB Elani – Misverstand Dam FUN RIDE for any claim or claims preferred against them by my dependents. I acknowledge that I have given indemnity form to each of my family members/ passengers and made them fully and aware and explain the above contents and that they have accepted and agreed to the conditions as set out above.

IN WITNESS WHEREOF I have hereunto set my hand at Moorreesburg on this27 of August 2016 in the presence of the undersigned witnesses:

Signature : ______ID Nr : ______Print Name : ______

As witnesses: 1______2 ______

FUNDURO funds go to NAC church80 fundraising

COST

R180.00 per riderPayment details

R120 per child on full track under 12yearsAccount Name : Executive It Solutions

R 120.00 per liftBank:FNB

KIDDIES TRACK AVAILABLE !!!! R80.00 for under 10 yearsBranch Code:210-515 Account no: 6214 829 5448

REFERENCE : FUNDURO AND Please use your name and surname

Documentation: From 07h30 - 09h30Riders Briefing: 09:30 - 09:50

Start of Outride: 10h00

Start:Coffee and snacks available for own cost

For more info: Mike Downey 082 573 5906 or