Waiver Release Form

Waiver Release of Liability and Indemnity Agreement

** All information on this form is kept confidential.

First Name*

Last Name*

Address*

Mobile Number*

Email Address*

Emergency Contact*

Emergency Contact Phone Number*

I hereby agree to the following: 1. “Bali Tiger” for the purposes of this declaration means Bali Tiger Hideaway Accommodation, registered in Indonesia under the name Pondok Wisata Punyan Medewi and includes its officers, agents, staff, contractors and/or employees.*

Yes

2. I accept that I am participating in the activities (hereinafter called “Activities”), during which I will be taking yoga, relaxation and meditation classes, surfing lessons, swims, guided tour and trek walks. And as is the case with any physical activity I accept these activities carry with them some degree of risk both to the person and property. Knowing the risk involved, I still wish to participate for the activities involved in the Activities and so expressly agree to assume the risk of injury or damage while participating in these activities.*

Yes

Please provide details of any limitations, injuries or medical conditions that we should be aware of (type none if not applicable):*

3. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Activities and any overseas travel precautions. I represent and warrant that I am physically fit and I have no medical conditions that would prevent my full participation in the Activities. I will inform Bali Tiger in writing of any health-related issues I have that may affect me whilst participating in the Activities. I understand that if I am pregnant, I will take necessary steps to ensure my doctor and health care providers know I am participating in this Activities. I assert that I am of fit health to participate in the Activities and will alert all organisers whose sessions I participate in that I am pregnant.*

Yes

4. In consideration of being permitted to participate in the Activities, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the Activities, including any travel and any or all activities done with the Activities group, or as an individual at the accommodation and facilities provided. In further consideration of being permitted to participate in the Activities, I knowingly, voluntarily and expressly waive and indemnify any claim I may have against Bali Tiger for injury or damages that I may sustain as a result of participating in the Activities. I, my heirs and legal representatives forever release, waive, discharge and covenant not to sue Bali Tiger for any injury or death caused by their negligence or other acts.*

Yes

5. Photographic and or visual images taken by Bali Tiger of my participation in the Activities may be used for general promotion. I give consent to this. *

YesNo

6. Travel Insurance is recommended and no responsibility is taken by Bali Tiger for any travel-related costs.*

Yes

I have read the above waiver release of liability and the indemnity agreement and both agree and fully understand its contents.*

Yes

Full Name*

Date*

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Thank you for completing the waiver form. All information on this form is kept confidential.