(Should any of the above change, please notify STACKS (PTY) LTD in writing.)
All information provided is factual and true at the date of submitting this form.
(as the responsible party) hereby acknowledge that:
• Upon signing this I agree to act as the responsible party and thus will be held liable for all fees payable as
invoiced to me by STACKS (PTY) LTD for the contract type and term as selected above.
• I agree to pay all fees payable before the 3rd day of each calendar month or 7 days from invoice date.
• I give permission for all children listed above to commence in the above selected program option provided
by STACKS (PTY) LTD.
• I understand that all these children participate entirely at their own risk and must exercise due care to
ensure their personal health and safety, and that of others.
• I understand that STACKS (PTY) LTD can not be held liable for any injuries or losses that might occur during
the testing and I hereby fully indemnify STACKS (PTY) LTD and its personnel, the organizers, all sponsors
and partners, volunteer groups, medical personnel and any and all other parties from any direct or indirect
loss or damage however caused arising from these children’s participation in the STACKS (PTY) LTD
sessions, or related to the sessions.
• I have explained to the children that they need to listen and follow any directions or advice affecting their
safety and that of others, given to them by STACKS (PTY) LTD.
• I warrant that all information supplied by me is true and correct.
• I will see to it that all parents of the children listed above complete the STACKS (PTY) LTD indemnity and
informed consent forms. We will also see to it that these parents complete a STACKS (PTY) LTD pre-
• I grant my permission in terms of section 51 of the electronic communications transactions act 25 of 2002,
to use my name, event information and photographs, video tapes, broadcasts, telecasts in which I may
appear free of charge. I accept that my personal information will remain confidential and hereby consent
to same being shared with the parties involved in the organization of the sessions for purposes of medical
care or promotion of activities related to the sessions.
TEL: 012 003 4642