1 Indemnity Form Full name Chinese name (if applicable) NRIC No. / Passport No. Phone Numbers : (Home) (Office) (Mobile) Address Date of Birth/ Age (as of 1/1/17) Occupation Marital status Please answer the following questions (*Please circle your answer): 1. Are you currently under doctor s supervision? YES / NO* 2. Are you currently recovering from any operation? YES / NO* 3. Do you suffer from any back, neck, leg, arm, heart complaints or any YES / NO* physical condition which could affect your participation in the Challenge? 4. Do you suffer from any nervous disorder or condition? YES / NO*
2 Person to contact in case of emergency Nature of Relationship Phone Numbers : : : (Home) (Office) (Mobile) NATURE OF CHALLENGE: THE 8 DAYS SHOPPING BAG DARE The participants of The 8 DAYS Shopping Bag Dare (the Challenge ) will be decided on a firstcome first-served basis. Each participant will select two shopping bags on display and hold them up for as long as they can in designated positions. Each round will last a maximum of 30 minutes. The last participant to hold up the shopping bags in the designated positions and/or complete the given task/s will win the respective prize. The detailed Rules and Terms and Conditions for participation in this Challenge are attached hereto.
3 DEED OF ACKNOWLEDGMENT, RELEASE & INDEMNITY In consideration of YTL Starhill Global Property Management Pte Ltd ( Starhill ) and Mediacorp Pte. Ltd. ( Mediacorp ) agreeing to allow me to participate in The 8 DAYS Shopping Bag Dare (the Challenge ), I (insert full name as in NRIC/Passport), NRIC No./Passport No.: hereby covenant and agree with Mediacorp as follows: 1. I fully understand and acknowledge that in choosing to participate, I acknowledge that I ACCEPT ALL RISKS ASSOCIATED WITH THE CHALLENGE and that such acknowledgement is a condition precedent to me taking part in any capacity in the Challenge. 2. I warrant that I have not at any time suffered any blackout, seizure, convulsion, fainting or dizzy spell, back, leg, arm or neck injury, or heart complaint and am not presently receiving treatment for any illness, disorder or injury which may render it unsafe for me to take part in the Contest. 3. I for myself, my executors, administrators and other personal representatives acknowledge that Mediacorp and Starhill, their respective related companies, and their respective officers, employees, servants and agents will not be responsible or liable for, and release and forever discharge Mediacorp and Starhill, their respective related companies and their respective officers, employees, servants, agents and all persons authorized by it or them or any of them from, any claim, liability, damages, cost, loss or expense whatsoever in respect of: Any injury or health problems to me (including nervous shock) and including any injury or health problems resulting in mental or physical illness whether temporary or permanent and injury or health problems resulting in death; Loss of earnings or earning capacity; Any impairment of enjoyment of life; Loss of or damage to my property and personal belongings; Pain and suffering; Death; and/or Any loss of any other kind whatsoever, arising out of my participation in the Challenge or arising from compliance with the attached Rules and Terms and Conditions (as may be amended from time to time) and I agree that this Deed of Acknowledgement, Release & Indemnity ( Deed ) may be pleaded to any such claim.
4 4. The releases contained in Clause 3 shall operate in respect of any loss or damage sustained or suffered however caused, including loss or damage suffered due to the negligence, omission, lack of reasonable foresight, lack of reasonable care or failure to take adequate precaution by Starhill or Mediacorp, their respective related companies and their respective officers, employees, servants and/or agents. 5. I warrant and acknowledge that I have not relied upon any expertise, representation, warranty or statement whatsoever of Starhill or Mediacorp, their respective related companies and/or their respective officers, employees, servants or agents in choosing to participate in the Challenge and I further acknowledge that Starhill and Mediacorp have advised that neither it, nor their respective related companies, their respective officers, employees, servants or agents have any experience or expertise whatsoever in relation to the activities involved in the Challenge. I understand that Starhill and Mediacorp and their respective related companies, their respective officers, employees, servants or agents are not actually suppliers of such activities. 6. I hereby indemnify and will keep Starhill and Mediacorp, their respective related companies and their respective officers, employees, servants or agents indemnified against any claim, demand, writ, summons, suit, action, proceeding, judgement, order, decree, damages, costs, loss or expense of any nature arising out of any breach of representation, warranty or undertaking herein or in relation to my participation in the Challenge. 7. I warrant that I am at least 18 years of age as at 1 January 2017 and that I have the legal capacity to enter the Challenge and agree to the Rules and Terms and Conditions. 8. In the event that any clause or part-clause of this Deed is deemed invalid or unenforceable, then the remaining clauses and part-clauses shall remain in full force and effect, and so far as possible, the said clause or part-clause shall be deemed modified to the minimum degree possible so as to comply with applicable law and be valid and enforceable. 9. This Deed shall be governed by and construed in accordance with Singapore law.
5 Participant to sign below: Signature Name NRIC No./Passport No. Date :. :.. :.. :...