Booking Form Sample

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Banking Details:
Pelonngwe Wellness Spa & Boutique Hotel
FNB Bank Account #: 62505287351 Branch: 258055

Disclaimer


Informed Consent and Acknowledgement

I hereby acknowledging to participate in any and all activities prepared by Pelonngwe Wellness Retreat during the Evoking Silence Retreat Camp. In exchange for my acceptance of said, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Pelonngwe Wellness Retreat & Spa, and all its respective officers, agents, and representatives from any and all liability for injuries arising out of traveling to, participating in, or returning from selected camp sessions.
In case of injury I hereby waive all claims against Pelonngwe Wellness Retreat & Spa. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including just leisurely walking up the mountain. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the participant's life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.
Permission is hereby granted to the attending medical practitioner or integrative medicine practitioner to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the injured with their concerned if they are conscious. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending medical practitioner to contact the personed named on the emergency contact in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach the emergency contact person.
Permission is also granted to the Pelonngwe Wellness Retreat & Spa and its affiliates including Directors, Coaches, and Team to provide the needed emergency treatment prior to the participants' admission to the medical facility.
Release authorized on the dates and/or duration of the registered season.
This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

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