Segway Marketing and Tourism (Pty) Ltd – Segway Indemnity Form It looks like your internet is very good, do you want to synchronize the data? Total Signed: Total Returning: Sync data Thank you for completing our waiver form. Your submission for Segway Indemnity Form event was processed successfully. Hi - welcome! Please let us know if you are a new customer, or a returning customer.... Make a selection New customer Returning customer Participants Name Participants Surname Participants email Are you a new customer? I'm a new customer Are you completing this on behalf of a minor? Make a selection No Yes For legal Guardian (All fields compulsory) Guardian Full Name and Surname Relationship to participant Guardian ID Number or passport number Guardians valid Email Address Guardians contact number (also for emergencies) Minor 1 Remove Minor's name Minor's Surname Minor's date of birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Minor's gender Make a selection Male Female Minor's age group Make a selection 123456789101112131415161718 Add New Participants First name Participants Last name Participants Valid Email Address Participants ID or Passport number or Date of Birth Contact_number Participants contact number Emergency Contact person Emergency Mobile Number Country Make a selection South Africa Australia Germany United Kingdom United States Netherlands India Namibia Afghanistan Albania Algeria American Samoa Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cape Verde Cambodia Cameroon Canada Cayman Central Chad Channel Islands Chile China Colombia Comoros Congo Costa Rica Cote d\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Faroe Islands Fiji Finland France French Polynesia Gabon Gambia Georgia Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Dem. 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Make a selection Brochure Word of mouth Printed advert Internet search Social media Road Signage Other By completing and submitting this form you are agreeing to the following: INDEMNITY AND WAIVER In this agreement: “SMT” means collectively and individually as the context dictates: Segway Marketing & Tourism (Pty) Ltd t/a Segway Gliding Tours and their subsidiary companies, affiliates, employees, directors, members, agents, shareholders and property upon which the tours are conducted; 1.1 “Activity” means the Segway tours conducted by Segway Gliding Tours, including but not limited to, the use of the Segways, roads and pathways and being conveyed by any moving vehicle. 2. I, the undersigned person or the legal guardian of the child stated below (“my child”), hereby acknowledge and agree, on my own behalf or on behalf of the child taking part in the Activity, as the case may be, that I: 2.1 am aware of and understand the serious dangers and risks to my / (my child’s) health and bodily person and those of others, including possible serious injury, infection and death that are associated with the Activity which may arise from, among other things: 2.1.1 the fact that the Activity takes place at considerable speed and on a machine where falling is an inherent danger; 2.1.2 the presence of pedestrians, vehicles when crossing roads, winds and other natural hazards at the Activity; and/or 2.1.3 the fact that the tour takes place along uneven surfaces, obstacles and/or loose ground 2.2 adhere to the instructions provided at the safety briefing and understand the safety requirements 2.3 am aware that it is my / (my child’s) responsibility to physically control, steer and brake myself on the Segway for the full duration of the tour and failure to do so may result in serious injury or possible death to myself or others; 2.4 warrant that I am / (my child is) in good health, that I am not pregnant, and that I am prepared to act responsibly at all times; 2.5 warrant that I am the legal guardian of or have the full consent of the legal guardian or am an adult legally responsible for the child named below; that I have full legal capacity to contract for him/her and that he/she is over the age of 10 2.6 waive any and all claims of whatsoever cause or nature, howsoever arising against SMT, which I / my child might have arising out of any harm, injury, death or loss suffered whilst participating in the Activity and whether arising from an act or omission, malfunction and/or negligence on the part of SMT; and 2.7 indemnify and hold SMT harmless from any and all damages, liabilities and claims of whatsoever cause or nature which may be made by my spouse, children and/or any other dependent of mine or third party who may suffer any damages, including but not limited to personal injury, death, loss of support or any other loss, arising from any cause whatsoever relating to their or my partaking in the Activity (including but not limited to any act or omission, malfunction and/or negligence on the part of SMT). 2.8 warrant that I am not intoxicated nor under the influence of alcohol and agree that I will be held liable for any costs arising from injuries, accidents or damage to any property should I be found to be intoxicated or under the influence of alcohol. Accept that I am liable for any costs arising from damage caused by myself to other property / persons involved This agreement is governed by the law of South Africa. This agreement is binding on my executors, curators, liquidators and heirs. I accept that SMT may, in its discretion and without obligation to do so, arrange and pay for emergency medical treatment, for and on behalf of myself, spouse, my children, or relatives and/or any person accompanying me. I acknowledge that I will be directly responsible to reimburse SMT for these expenses. I agree that SMT may, in its sole discretion, refuse to permit me / my child to participate or continue to participate in the Activity at any time, for any reason and that SMT is not obliged to reimburse the fees already paid as a result of such non-participation in the Activity. I acknowledge and give permission to the corporations to use my, or that of my family’s images in all advertising and marketing publications, both print and / or electronic, and be stored electronically, available to all employees and clients of the corporations. I also agree that my and / or the images of my family will be freely available to use now and in the future without notice and any compensation. COVID-19 Should your temperature exceed 37.8C or greater you won’t be eligible to participate in a tour. I agree to these terms and conditions