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Consent and Indemnity Form
. Events and Activities
.

To the Provincial Commissioner, Scouter,

I, (Full names of Parent / Legal Guardian) G I O V A N N I R O S S I

of (Address) 4 1 S E C O N D C R E S C E N T , F I S H H O E K

C A P E T O W N Postal Code 7 9 7 5

Home Telephone Cell Number 0 6 3 4 1 1 9 4 6

being the Parent / Legal Guardian of (minor child’s full name), hereinafter referred to as ‘Ward’,

V A L E N T I N O I V A N R O S S I

a member of the F I S H H O E K 2 N D S C O U T S Group,

hereby permit him/ her to partake in the activity/camp referred to below

Camp/Activity: B E A C H E V E N I N G

Date/Duration 2 0 2 2 / 0 2 / 2 5 Location/Venue F I S H H O E K

I hereby appoint and authorise the Scouter, Chairman or Commissioner in charge to act in my place as parent/guardian with
full authority to consent to my Ward undergoing surgical and/or medical treatment. I undertake to pay the costs of such
treatment.

I hereby DO/ DO NOT give permission for my Ward to participate in any water activities.
I fully understand and accept that all activities are undertaken at my Wards own risk.

I am aware that neither SCOUTS South Africa, nor its Chairmen, Commissioners, Scouters, agents, employees, volunteers or
any person associated with SCOUTS South Africa accept responsibility for any loss, injury or damage that the person or
property of my Ward may sustain whilst engaged in any Scouting, including inter-alia transport to and from the activity.

I hereby waive any right that I or my Ward may have to claim compensation against SCOUTS South Africa or its Chairmen,
Commissioners, Scouters, agents, employees, volunteers or other members, in respect of any loss, injury or damage incurred
whilst engaged in any Scouting activity howsoever arising and whether as a result of negligence or otherwise and I indemnify
SCOUTS South Africa against all such claims.

I agree and authorize that photo’s, statements, audio – visual recordings, video and sound bites taken, recorded and
collected from my Ward during activities with SCOUTS South Africa may be used free of charge and at the discretion of
SCOUTS South Africa as part of their marketing, communication and fundraising campaigns.

Signed: __________________________________ Witness: ____________________________________

Mother/Father/Legal Guardian

Dated this _______________________ Day of _________________________________ 20 ______________

Name Doctor Tel No

Preferred Hospital F A L S E B A Y

Medical Aid Scheme N / A

Medical Aid Number N / A

Med Aid Prinicpal Member N / A

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E-mail: info@scouting.org.za Website: www.scouting.org.za Tel: 0860 SCOUTS

2013/v1
 . SCOUTS South Africa
. Consent and Indemnity Form
. Events and Activities
.

In the case of an emergency it is vital that the Scouter and/or person in Charge has as much
personal information as possible. It is to your own benefit to fill this in completely and accurately!

Details of Scout

Full Names V A L E N T I N O I V A N R O S S I

ID Number 1 0 0 6 1 9 Date of Birth 1 9 0 6 1 0 Age 1 1

Day Month Year

Allergies N O N E

Medication (specific times/dosage/etc) N O N E

Previous medical conditions or any other medical conditions you feel are of relevance
N / A

Infectious Diseases N / A

Physical Disabilities N / A

Special Dietary Requirements N / A

Parents Contact Details

Fathers Details Mothers Details

Name G I O V A N N I L E R U S H A

R O S S I R O S S I

Home Phone

Work Phone 0 2 1 3 0 0 3 1 8 7

Cell Phone 0 6 3 4 1 1 9 7 4 6 0 7 9 8 5 4 9 9 5 7

Contact First (tick) ✔

Alternatively contact I V A N R O S S I
0 8 4 4 3 2 0 4 6 1

Page 2/2

E-mail: info@scouting.org.za Website: www.scouting.org.za Tel: 0860 SCOUTS

2013/v1