I, the undersigned,

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am of my own will and volition attending and/or participating in the educational tour at the Clover Visitors Centre.

I, for myself, my heirs, successors, executors, and subrogates hereby irrevocably and intentionally waive and release, unconditionally indemnify and hold harmless and Clover S.A. Proprietary Limited (including its holding company and/or any subsidiary thereof) (“Clover”), its officers, directors, employees, affiliated companies and agents, against any and all claims, liabilities, losses, damages, costs and expenses, whether direct, indirect, consequential or otherwise, arising from any cause whatsoever from my attendance at or participation in any way howsoever at the Clover Visitors Centre.

In the event that I become incapacitated due to any accident and/or incident which may occur during the Clover Visitors Centre, I hereby grant permission to Clover (or any of its authorized representatives) to render or arrange for immediate medical or other treatment as may be immediately necessary, and agree that I shall assume full responsibility for any costs arising out of such medical or other treatment.

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Signed on this the day of 2016.

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INDEMNITY FORMINDIVIDUAL