Entry number __________
I the undersigned,
Full names and Surname _____________________________________________________________
Identity number
Name of next of kin___________________________ Cell next of kin
herewith indemnifies
The “NHK Noordelike Pietersburg” church and its owners, guides and all co participants taking part in
the “KREMETART 4x4 FUN RUN” (Hereinafter referred to as "the event") in respect of any damage to
my property or in respect of injuries which I might sustain (including death), irrespective whether I
sustained such damage, injuries or death while attending the event as a driver, a passenger or as a
In the event of me being a driver of a vehicle I declare that I am fully acquainted with the capabilities
and shortcomings of the particular vehicle that I am driving during the event as well as with my own
capabilities and shortcomings, specifically pertaining to the terrain and each obstacle and the route
in general. I further declare that I have not taken any alcohol for at least 8 hours before the event
and I undertake not to do so during the event in which case I may be prohibited to participate.
In the event of me being a passenger in any vehicle during the event I specifically declare that I am
fully satisfied that the driver is capable of safely handling the vehicle, specifically pertaining to each
obstacle and the route in general and I indemnify the driver in case of damage to property, injury or
Medical Aid particulars:
Name of Fund _________________________
Membership number ______________________
Full name and surname of main member ______________________________________________
Signed at __________________________ on the _______ day of __________________ 20___
(Parent / Legal guardian to sign if under the age of 21)