Indemnity Form












PERSONAL INFO

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  • Colombia+57

  • Comoros (‫جزر القمر‬‎)+269

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  • Congo (Republic) (Congo-Brazzaville)+242

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  • Egypt (‫مصر‬‎)+20

  • El Salvador+503

  • Equatorial Guinea (Guinea Ecuatorial)+240

  • Eritrea+291

  • Estonia (Eesti)+372

  • Ethiopia+251

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  • Germany (Deutschland)+49

  • Ghana (Gaana)+233

  • Gibraltar+350

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  • Grenada+1473

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  • Guam+1671

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  • Guyana+592

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  • Jamaica+1876

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  • Jersey+44

  • Jordan (‫الأردن‬‎)+962

  • Kazakhstan (Казахстан)+7

  • Kenya+254

  • Kiribati+686

  • Kosovo+383

  • Kuwait (‫الكويت‬‎)+965

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  • Laos (ລາວ)+856

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  • Mali+223

  • Malta+356

  • Marshall Islands+692

  • Martinique+596

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  • Mayotte+262

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  • Micronesia+691

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  • Monaco+377

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  • Montserrat+1664

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  • Mozambique (Moçambique)+258

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  • Nicaragua+505

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  • Nigeria+234

  • Niue+683

  • Norfolk Island+672

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  • Northern Mariana Islands+1670

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  • Oman (‫عُمان‬‎)+968

  • Pakistan (‫پاکستان‬‎)+92

  • Palau+680

  • Palestine (‫فلسطين‬‎)+970

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  • Romania (România)+40

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  • Rwanda+250

  • Saint Barthélemy+590

  • Saint Helena+290

  • Saint Kitts and Nevis+1869

  • Saint Lucia+1758

  • Saint Martin (Saint-Martin (partie française))+590

  • Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508

  • Saint Vincent and the Grenadines+1784

  • Samoa+685

  • San Marino+378

  • São Tomé and Príncipe (São Tomé e Príncipe)+239

  • Saudi Arabia (‫المملكة العربية السعودية‬‎)+966

  • Senegal (Sénégal)+221

  • Serbia (Србија)+381

  • Seychelles+248

  • Sierra Leone+232

  • Singapore+65

  • Sint Maarten+1721

  • Slovakia (Slovensko)+421

  • Slovenia (Slovenija)+386

  • Solomon Islands+677

  • Somalia (Soomaaliya)+252

  • South Africa+27

  • South Korea (대한민국)+82

  • South Sudan (‫جنوب السودان‬‎)+211

  • Spain (España)+34

  • Sri Lanka (ශ්‍රී ලංකාව)+94

  • Sudan (‫السودان‬‎)+249

  • Suriname+597

  • Svalbard and Jan Mayen+47

  • Swaziland+268

  • Sweden (Sverige)+46

  • Switzerland (Schweiz)+41

  • Syria (‫سوريا‬‎)+963

  • Taiwan (台灣)+886

  • Tajikistan+992

  • Tanzania+255

  • Thailand (ไทย)+66

  • Timor-Leste+670

  • Togo+228

  • Tokelau+690

  • Tonga+676

  • Trinidad and Tobago+1868

  • Tunisia (‫تونس‬‎)+216

  • Turkey (Türkiye)+90

  • Turkmenistan+993

  • Turks and Caicos Islands+1649

  • Tuvalu+688

  • U.S. Virgin Islands+1340

  • Uganda+256

  • Ukraine (Україна)+380

  • United Arab Emirates (‫الإمارات العربية المتحدة‬‎)+971

  • United Kingdom+44

  • United States+1

  • Uruguay+598

  • Uzbekistan (Oʻzbekiston)+998

  • Vanuatu+678

  • Vatican City (Città del Vaticano)+39

  • Venezuela+58

  • Vietnam (Việt Nam)+84

  • Wallis and Futuna (Wallis-et-Futuna)+681

  • Western Sahara (‫الصحراء الغربية‬‎)+212

  • Yemen (‫اليمن‬‎)+967

  • Zambia+260

  • Zimbabwe+263

  • Åland Islands+358

  • Afghanistan (‫افغانستان‬‎)

  • Åland Islands (Åland)

  • Albania (Shqipëri)

  • Algeria (‫الجزائر‬‎)

  • American Samoa

  • Andorra

  • Angola

  • Anguilla

  • Antigua and Barbuda

  • Argentina

  • Armenia (Հայաստան)

  • Aruba

  • Australia

  • Austria (Österreich)

  • Azerbaijan (Azərbaycan)

  • Bahamas

  • Bahrain (‫البحرين‬‎)

  • Bangladesh (বাংলাদেশ)

  • Barbados

  • Belarus (Беларусь)

  • Belgium (België)

  • Belize

  • Benin (Bénin)

  • Bermuda

  • Bhutan (འབྲུག)

  • Bolivia

  • Bosnia and Herzegovina (Босна и Херцеговина)

  • Botswana

  • Brazil (Brasil)

  • British Indian Ocean Territory

  • British Virgin Islands

  • Brunei

  • Bulgaria (България)

  • Burkina Faso

  • Burundi (Uburundi)

  • Cambodia (កម្ពុជា)

  • Cameroon (Cameroun)

  • Canada

  • Cape Verde (Kabu Verdi)

  • Caribbean Netherlands

  • Cayman Islands

  • Central African Republic (République Centrafricaine)

  • Chad (Tchad)

  • Chile

  • China (中国)

  • Christmas Island

  • Cocos (Keeling) Islands (Kepulauan Cocos (Keeling))

  • Colombia

  • Comoros (‫جزر القمر‬‎)

  • Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)

  • Congo (Republic) (Congo-Brazzaville)

  • Cook Islands

  • Costa Rica

  • Côte d’Ivoire

  • Croatia (Hrvatska)

  • Cuba

  • Curaçao

  • Cyprus (Κύπρος)

  • Czech Republic (Česká republika)

  • Denmark (Danmark)

  • Djibouti

  • Dominica

  • Dominican Republic (República Dominicana)

  • Ecuador

  • Egypt (‫مصر‬‎)

  • El Salvador

  • Equatorial Guinea (Guinea Ecuatorial)

  • Eritrea

  • Estonia (Eesti)

  • Ethiopia

  • Falkland Islands (Islas Malvinas)

  • Faroe Islands (Føroyar)

  • Fiji

  • Finland (Suomi)

  • France

  • French Guiana (Guyane française)

  • French Polynesia (Polynésie française)

  • Gabon

  • Gambia

  • Georgia (საქართველო)

  • Germany (Deutschland)

  • Ghana (Gaana)

  • Gibraltar

  • Greece (Ελλάδα)

  • Greenland (Kalaallit Nunaat)

  • Grenada

  • Guadeloupe

  • Guam

  • Guatemala

  • Guernsey

  • Guinea (Guinée)

  • Guinea-Bissau (Guiné Bissau)

  • Guyana

  • Haiti

  • Honduras

  • Hong Kong (香港)

  • Hungary (Magyarország)

  • Iceland (Ísland)

  • India (भारत)

  • Indonesia

  • Iran (‫ایران‬‎)

  • Iraq (‫العراق‬‎)

  • Ireland

  • Isle of Man

  • Israel (‫ישראל‬‎)

  • Italy (Italia)

  • Jamaica

  • Japan (日本)

  • Jersey

  • Jordan (‫الأردن‬‎)

  • Kazakhstan (Казахстан)

  • Kenya

  • Kiribati

  • Kosovo (Kosovë)

  • Kuwait (‫الكويت‬‎)

  • Kyrgyzstan (Кыргызстан)

  • Laos (ລາວ)

  • Latvia (Latvija)

  • Lebanon (‫لبنان‬‎)

  • Lesotho

  • Liberia

  • Libya (‫ليبيا‬‎)

  • Liechtenstein

  • Lithuania (Lietuva)

  • Luxembourg

  • Macau (澳門)

  • Macedonia (FYROM) (Македонија)

  • Madagascar (Madagasikara)

  • Malawi

  • Malaysia

  • Maldives

  • Mali

  • Malta

  • Marshall Islands

  • Martinique

  • Mauritania (‫موريتانيا‬‎)

  • Mauritius (Moris)

  • Mayotte

  • Mexico (México)

  • Micronesia

  • Moldova (Republica Moldova)

  • Monaco

  • Mongolia (Монгол)

  • Montenegro (Crna Gora)

  • Montserrat

  • Morocco (‫المغرب‬‎)

  • Mozambique (Moçambique)

  • Myanmar (Burma) (မြန်မာ)

  • Namibia (Namibië)

  • Nauru

  • Nepal (नेपाल)

  • Netherlands (Nederland)

  • New Caledonia (Nouvelle-Calédonie)

  • New Zealand

  • Nicaragua

  • Niger (Nijar)

  • Nigeria

  • Niue

  • Norfolk Island

  • North Korea (조선 민주주의 인민 공화국)

  • Northern Mariana Islands

  • Norway (Norge)

  • Oman (‫عُمان‬‎)

  • Pakistan (‫پاکستان‬‎)

  • Palau

  • Palestine (‫فلسطين‬‎)

  • Panama (Panamá)

  • Papua New Guinea

  • Paraguay

  • Peru (Perú)

  • Philippines

  • Pitcairn Islands

  • Poland (Polska)

  • Portugal

  • Puerto Rico

  • Qatar (‫قطر‬‎)

  • Réunion (La Réunion)

  • Romania (România)

  • Russia (Россия)

  • Rwanda

  • Saint Barthélemy (Saint-Barthélemy)

  • Saint Helena

  • Saint Kitts and Nevis

  • Saint Lucia

  • Saint Martin (Saint-Martin (partie française))

  • Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)

  • Saint Vincent and the Grenadines

  • Samoa

  • San Marino

  • São Tomé and Príncipe (São Tomé e Príncipe)

  • Saudi Arabia (‫المملكة العربية السعودية‬‎)

  • Senegal (Sénégal)

  • Serbia (Србија)

  • Seychelles

  • Sierra Leone

  • Singapore

  • Sint Maarten

  • Slovakia (Slovensko)

  • Slovenia (Slovenija)

  • Solomon Islands

  • Somalia (Soomaaliya)

  • South Africa

  • South Georgia & South Sandwich Islands

  • South Korea (대한민국)

  • South Sudan (‫جنوب السودان‬‎)

  • Spain (España)

  • Sri Lanka (ශ්‍රී ලංකාව)

  • Sudan (‫السودان‬‎)

  • Suriname

  • Svalbard and Jan Mayen (Svalbard og Jan Mayen)

  • Swaziland

  • Sweden (Sverige)

  • Switzerland (Schweiz)

  • Syria (‫سوريا‬‎)

  • Taiwan (台灣)

  • Tajikistan

  • Tanzania

  • Thailand (ไทย)

  • Timor-Leste

  • Togo

  • Tokelau

  • Tonga

  • Trinidad and Tobago

  • Tunisia (‫تونس‬‎)

  • Turkey (Türkiye)

  • Turkmenistan

  • Turks and Caicos Islands

  • Tuvalu

  • Uganda

  • Ukraine (Україна)

  • United Arab Emirates (‫الإمارات العربية المتحدة‬‎)

  • United Kingdom

  • United States

  • U.S. Minor Outlying Islands

  • U.S. Virgin Islands

  • Uruguay

  • Uzbekistan (Oʻzbekiston)

  • Vanuatu

  • Vatican City (Città del Vaticano)

  • Venezuela

  • Vietnam (Việt Nam)

  • Wallis and Futuna

  • Western Sahara (‫الصحراء الغربية‬‎)

  • Yemen (‫اليمن‬‎)

  • Zambia

  • Zimbabwe

EMERGENCY CONTACT INFO

MEDICAL HISTORY

COVID-19 COMPLIANCE


COVID-19 Symptoms

YESNO


COVID-19 Symptoms

YESNO


COVID-19 Symptoms

YESNO

ACTIVITY (Tick appropriately)

CYCLINGHIKINGBUNGEE / RAFTINGRAFTINGOTHER

INDEMNITY

I wish to join the (trip/activity/camp) organized by Xtrym Adventures & Safaris

from

to

and abide by the Rules and Regulations set by both the Xtrym Adventures & Safaris and the Event Organising Committee. I am fully aware of the possible risks involved and accept the same, not withstanding the fact that this trip/activity/camp is intended only for those without medical problems and who are fit enough to indulge in physical activities. I confirm that I am enrolling on my own volition and I shall not hold Xtrym Adventures & Safaris, its servants and organisers responsible or in any way liable for my death, injury, disability or any loss or damage whatsoever arising from any cause in connection with the trip/activity/camp or my participation therein.

I hereby indemnify and agree to keep the Xtrym Adventures & Safaris, its management, servants and organisers of the event fully indemnified against all claims, loss or damage whatsoever in respect of death, injury, disability or any loss or damage whatsoever arising from any cause in connection with the trip/activity/camp or my participation therein.