Medical Fitness Declaration & Indemnity Form

I, MR/MRS/MISS

as parent and or guardian of

do confirm that

born on

suffers/does not suffer from any Medical Condition/Ailment/Allergy (if applicable state)
as has been confirmed by his doctor.

I, therefore, confirm and warrant to George Njogu Wainaina, that my Son is in and of good health and he is thus fit/unfit to participate in any and all rigorous physical exercise(s) and programme activity(ies). I further confirm and declare that I have granted him permission to participate in the rigorous physical exercise(s) and programme activity(ies) in the course of and during the Ndeiya House Irua 2024 programme.

I agree to indemnify George Njogu Wainaina and ther volunteers, consultants, trainers, facilitators, employees, independent contractors, agents from any liability. claims or law suits brought against any and or all of them by myself, my Son or others, that arises directly or indirectly from my Son's participation in the Ndeiya House Irua 2024 programme generally and particularly in the rigorous physical exercise(s) and activity(ies).

EMERGENCY MEDICAL TREATMENT:

In the event of any emergency arising in my absence in the course of and or during my Son's participation in the rigorous physical execise(s) and activity(ies) under the Ndeiya House Irua 2024 programme, I gave permission to George Njogu Wainaina to transport my Son to the nearest hospital that they may deem fit for medical treatment. In the event of any emergency, if you are unable to reach me at the telephone number herein state, you are at liberty to contact my following duly authorized representative:

Name:

Phone Number:

ADDITIONAL MEDICAL INFORMATION

Medication my Son is taking at present:

Family insurance particulars:

(Attach a photocopy of any necessary medical card or other instrument/document used to accesss medical care under the insurance)

Family Doctor:

Phone Number:

I confirm and warrant that the information I have provided herein is accurate and the same been supplied in my full knowledge that it will be relied upon without need for further enquiry from or confirmation by me.

Signature of Parent:

Date:

Telephone number:

George Njogu Wainaina (Muruithiria Mucii)
Signature: