Travel Risk Assessment and Indemnity Form

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Travel Risk Assessment and Indemnity Form

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Travel Risk Assessment and Indemnity Form

KFM Partnership*

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Member

Name*

Prefix First Last

Gender

Date of Birth*

MM slash DD slash YYYY

Passport Number*

Contact Number*

*Start with Area Code e.g 0027... or +27

Email*

Next of Kin*

Country of Residence

Country of Travel

Mode of Transportation to and from Malawi*

Bus

Flight

Private Car

Arrival Date*

DD slash MM slash YYYY

Arrival Time*

:

Date of Departure*

DD slash MM slash YYYY

Departure Time*

:

Medical questionnaire:

Disclaimer : Please note that advice to travel is given based on the details you give on this form. It is your responsibility to give all relevant information.

1. Are you critically ill?*

Yes

No

2. Are you blind?*

Yes

No

3. Do you have hearing problems?*

Yes

No

4. Are you currently under medical care as an inpatient(hospitalized)*

Yes

No

5. Are you on respiratory support devices such as oxygen?*

Yes

No

6. Are you wheelchair bound?*

Yes

No

7. Are you using any form of walking aid?*

Yes

No

8. Are you pregnant?*

Yes

No

How many months pregnant

9. Have you recently tested positive for covid 19?*

Yes

No

10. Are you vaccinated?*

Yes

No

11. Do you have a vaccine certificate?*

Yes

No

12. Do you need a covid certificate on return flight?*

Yes

No

Have you experienced the following recently:

Please check the applicable one

Cough?*

Yes

No

Fever?*

Yes

No

Diarrhoea?*

Yes

No

Vomiting?*

Yes

No

Loss of consciousness?*

Yes

No

Blurred vision?*

Yes

No

Shortness of breath?*

Yes

No

Indemnity

I am voluntarily applying to attend the Partners Retreat through KFM in Lilongwe, Malawi for religious purposes.*

Yes

No

I agree that KFMI will take care of my accommodation in a hotel( deluxe room or standard room); my 3 meals ; my Covid 19 certificate upon departure to my country of residence and transportation to and from the airport on the dates designated for the tour*

Yes

No

I acknowledge that transportation from my country of residence to Lilongwe-Malawi, passport or visa applications, passport charges, deposit and cancellation insurance, luggage insurance and related matters are my sole responsibility*

Yes

No

I agree that I am entirely responsible for my own personal safety, health, and mental, physical, emotional, and general well-being during the Partners Retreat.*

Yes

No

I agree that if I have a condition that may pose a threat to travelling by air or for long hours I will need to produce a doctor’s fit-to-travel certificate?*

Yes

No

I release KFMI its directors, officers, employees, volunteers, agents, contractors, successors and assigns and administrators from any claims of any kind which may result from any accident, injury, damage, loss or death that may occur to me or my family while attending the Partners Retreat.*

Yes

No

I am aware that KFMI only acts as facilitator for my trip and shall not be liable as principals for arrangements made or tickets issued for my transportation or accommodation for the duration of the programme.*

Yes

No

I understand that I will have a booking secured when a full payment or deposit of 50% is paid for reservation is made, the balance of which I will settle within 7 days prior to the scheduled departure (unless otherwise specified prior to payment).*

Yes

No

I acknowledge that the duration of my stay for the Partners Retreat will be based on the dates provided by KFMI Team, extension of my stay will be at my own expense.*

Yes

No

I understand that taking care of my personal goods is my responsibility during the tour and KFMI will not be held liable for any damaged or loss of such.*

Yes

No

I know that the retreat is a religious tour therefore consumption of alcohol, smoking and the use of illegal drugs is prohibited by KFMI*

Yes

No

I agree that should I wish to make a cancellation or withdrawal during the retreat, I will produce a written notice to KFMI, and if I cancel the trip before the date of departure I will be charged a minimum of 30% cancellation fee.*

Yes

No

I agree that if I am travelling with a minor, I will take full responsibility of his/her wellbeing and I will also fill up a separate travel risk assessment form for the minor.*

Yes

No

Consent*

By writing my name below, I hereby sign to acknowledge that the information provided above is true and correct and to accept all responsibility and liability

Name

First Last

Comments

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