Your Name (required)
Telephone Number (required)
Gender (required) MaleFemale
ID / Passport # (required)
Nationality (required)
Your Email (required)
Physical Address in Nairobi (required)
Contact Name (required)
Relationship (required)
Email
DO YOU HAVE ANY SPECIAL MEDICAL SITUATION THAT THE WE SHOULD BE AWARE OF? YESNO ARE YOU? EPILEPTICDIABETICASTHMATICOTHER IF YES, EXPLAIN WHAT SHOULD BE DONE IN CASE OF AN EMERGENCY.
HAVE YOU BEEN TESTED FOR COVID-19? YESNO
ACCREDITED CENTRE TESTED (required)
DATE TESTED? (required)
WAS THE RESULT POSITIVE OR NEGATIVE? POSITIVENEGATIVE
HAVE YOU SINCE BEEN CLEARED AS COVID-19 FREE? YESNO
FOR YOUR SAFETY AND THAT OF THE REST OF THE PARTICIPANTS, WE CANNOT ALLOW YOU TO ATTEND AT THIS TIME.
CERTIFICATE NUMBER: CERTIFICATE DATE: DO YOU EXIBIT ANY SYMPTOMS AS OUTLINED IN THE KENYA MINISTRY OF HEALTH GUIDELINES WEBSITE (CLICK TO VIEW)?
YESNO
DO YOU EXIBIT ANY SYMPTOMS AS OUTLINED IN THE KENYA MINISTRY OF HEALTH GUIDELINES WEBSITE (CLICK TO VIEW)?
DO YOU EXHIBIT ANY SYMPTOMS AS OUTLINED IN THE KENYA MINISTRY OF HEALTH GUIDELINES WEBSITE (CLICK TO VIEW)?
PLEASE PROCEED WITH THE REST OF THE FORM
CYCLINGHIKINGBUNGEE / RAFTINGRAFTINGOTHER
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.
SIGNATURE (required)
Date (required)
