Test Form - Elephant Plains Game Lodge

First Name *

Last Name *

Date and Approximate Time of Arrival *

ID Number *

Email *

Phone *

Address *

Street Address (line 1)

Address

Street Address (line 2)

City *

State / Province *

Postal / Zip Code *

Vehicle Registration Number

For Self-drive guests only

Emergency Contact Name *

Not traveling with you.

Emergency Contact Number *

Would you like your room to be serviced by housekeeping during your stay? *

Yes, I will require a morning & evening service
Yes, I will require a morning-only service
Yes, I will require an evening turn-down service
No, I require no housekeeping services during my stay

Bed configuration preference:

Double
Twin
Family
Single

Will you be joining us for lunch @ 14:00 on the day of your arrival? *

Do you have any dietary requirements or food allergies? Please specify: *

Are you celebrating a special occasion? Please specify: *

Do you have any special requests? Please specify: *

Please rate your overall fitness level *

Unfit
Average fitness
Very fit

Do you suffer from any of the following chronic ailments?

Diabetes
Cardiovascular Disease
Hypertension

Do you have any physical impairments? Please indicate:

Are you a smoker or have you recently quit smoking? *

Approximate age *

Under 65 years
66 - 70 years
71 - 85 years
86+ years

In the last 14 days, to your knowledge, have you been in close contact with anyone who tested positive for Covid-19, is in quarantine, or waiting for Covid-19 test results? *

Are you awaiting test results of a Covid-19 test? *

Indemnity (see below) *

I have read, understood and accept the indemnities set out below:

Covid-19 Indemnity

COVID-19 INDEMNITY Indemnity given in favour of Elephant Plains Game Lodge (Company Registration Number: 2009/113531/23) [hereinafter referred to as "the Company"]:

WHEREAS a result of the Covid-19 pandemic that has befallen the world and theRepublic of South Africa;

AND WHEREAS the President of the Republic of South Africa has declared a state of National Disaster and more recently various levels of a National Lockdown;

NOW THEREFORE the Parties agree as follows:

The Client hereby confirms that he/she has been advised about the current state of affairs in the country in re the Covid-19 pandemic and subsequent Lockdown announced by the government;
The Client confirms that he/she has been informed of the health risks and symptoms of the Covid-19 virus as well as procedures to be followed to minimise the risk of contracting the virus;
The Client accepts that the Company has done, and will continue to do, all that it reasonably could/can in re preventative measures including sanitary measures, informationals, education, social-distancing and other measures as prescribed in the published Regulations to the Disaster Management Act and related legislation;
The Client further accepts that the risk of infection and/or general stages of increased national/global concern may require both Parties to adapt to the circumstances dictated to it by the Covid-19 virus, good business practices, advice taken from health officials and/or government instructions/Regulations for the foreseeable future;
The Client confirms that it accepts the said risks and still wishes to attend, utilise, procure, and/or participate in any activity, venue, event, trip, tour and/or package provided by the Company;
The Client confirms that the activity, venue, event, trip, tour and/or package structure may have to be amended as a result of the measures implemented by government and/or the Company, but that the value of attending, utilising, procuring and/or participating will still be received, and its objectives achieved;
The Client hereby indemnifies the Company, its staff, sub-contractors and agents against all and any claims that he/she may have against it as a result of his/her exposure to the accepted risks including, but not limited to, injury, loss or damage to his/her person or property and/or his/her illness or diagnosis with any disease, whether such claims may be lodged as a direct, indirect and/or consequential damages/contractual claim;
The Client further indemnifies the Company, its staff, sub-contractors and agents against all and any claims by any third party against the Company as a result of the Client's actions or omissions that may have caused a third party injury, loss or damage to his/her person or property and/or his/her illness or diagnosis with any disease, whether such claims may be lodged as a direct, indirect and/or consequential damages/contractual claim.

Guest Indemnity

I have made an application to participate in or be associated with the activities or undertakings of Elephant Plains Game Lodge and/or its duly appointed officers or employees.
To the extent to which this may be necessary, I have obtained the authority of my lawful guardian to make such an application and enter into such indemnity.
My general health is good and that there is nothing that renders me unfit to participate in, or be involved with, Elephant Plains Game Lodge's activities, or undertakings, or to give this indemnity.
I am fully aware of and understand that in entering into any relationship with Elephant Plains Game Lodge, whether contractual or otherwise, I may be exposing myself to the risk or possibility of danger, harm or damage to my person or property arising from Elephant Plains Game Lodge's activities or undertakings, which, by my signature hereto, I acknowledge myself to be fully aware of.
I am aware that I am entering an endemic Malaria area and acknowledge that I have been advised to take the necessary precautions for myself and any minor children under my control.
Notwithstanding the foregoing, I undertake at all times to obey immediately and without query, any order, command, or request that may be made to me at any stage in the course of any activities conducted by Elephant Plains Game Lodge, or their duly authorised officers or employees and I acknowledge that such order, command or request will be made for the purpose of ensuring my own personal safety, alternatively the safety of others in whose company I may be.
I voluntarily and with full knowledge of the meaning and effect hereof, assume any and all risks or dangers whatsoever which may be inherent in, arise or be associated with any of the undertakings or activities associated with Elephant Plains Game Lodge and its employees wherever the same may arise and, together with my heirs, executors, administrators, or assigns, hereby release Elephant Plains Game Lodge or any of its members, employees, officers, or agents from any duty of care towards me in connection therewith, and hereby unconditionally indemnify and hold them harmless from any liability whatsoever from any and all claims which would otherwise accrue to me or my heirs, executors, administrators or assigns arising from my participation or association with any such activities or undertakings, whether or not any such claim(s) may arise through the negligence of any person or from any of the risks, dangers or hazards occurring in the course of my association with Elephant Plains Game Lodge.

The amenities and facilities provided by Elephant Plains Game Lodge have been conceived, designed and constructed with your enjoyment, recreation and safety in mind. Nevertheless, we regret that the owners, management, employees and agents hereby stipulate that they are unable to accept liability or responsibility for any injury, loss or damage of any nature whatsoever, whether arising from negligence or from any other cause whatever nature, which is suffered by any person who enters the premises or by the dependants or principals of such person and is hereby recorded that entry occurs absolutely at own risk and that the owners, management, servants and agents are released from and indemnified against any and all claims of whatever nature. In signing the document I also agree not to claim the unenforceability of this agreement.