Affidavit – Red Mangrove Galapagos & Ecuador Lodges

Name:

Nationality:

Identity Document (Passport or ther):

Address:

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I declare that I have been properly informed by the owner of the Red Mangrove Galapagos & Ecuador Lodges, Ecuadorian Company, Taxpayer Identification No. 0991462007001, hereinafter the operator, on the conditions and risks involved in the contracted voyage and its related activities.

I declare that I am fully aware that the voyage and related activities organized by the operator will be conducted in rough places away from urban centers, which do not have hospital and/or health care facilities capable of providing medical services – beyond first aid – while in The Galapagos Islands promptly available if I suffer an accident, disease and/or any other type of physical or psychological condition affecting the health of the undersigned.

I especially put on record that I have been informed by the operator on the conditions and physical capacities required to develop the various activities, as well as the fact that medical care beyond first aid will not be possible while in The Galapagos Islands.

Further, I inform the operator that I do not suffer any disease or disability that might increase the risks of the voyage or activities to the extent of preventing me from taking such voyage or conducting such activities.

Finally, I declare that I am aware that during the contracted voyage I might suffer pain or accidents related to it and other pains or accidents not related to it such as, for example, and without the following enumeration being restrictive, heart arrests, vascular and/or encephalic accidents, respiratory failures, etc.

Without prejudice to the unwaiving rights I am vested with according to the legal status applicable to the voyage contract and during the term proper to it, if I take part in any activity organized by the operator, I expressly declare that the carrier – and/or its dependants and/or associates are not liable for accidents and/or diseases that might affect me or occur during the conduct of such activities which are not in the scope and related periods.

Consequently, I, the undersigned, do hereby expressly declare, without any reservation, that I have decided to participate, remain in and/or develop the activities organized by the operator which are not within the scope and period aforementioned under my own and entire responsibility.

Further, the operator and/or its dependants and/or associates shall not be responsible for any injuries and sequels, permanent or temporary that I might suffer in consequence of the diseases and/or accidents resulting from the aforementioned activities nor for the damages that such injuries or sequels might cause me.

I expressly put on record that, even in the event of accidental decease or death caused by the injuries and/or diseases suffered in the course of such activities, the operator and/or its dependents and/or associates shall be under no responsibility.

Finally, I put on record that I am accompanied by the following minors (name, identity document and address):

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Such minors will conduct the activities and tours organized by the carrier under my own responsibility. Consequently, I release the operator and/or its dependents and/or associates from any responsibility for the diseases, accidents, injuries, damages and/or losses, including death, that might be suffered by the aforementioned minors during the said activities or in consequence thereof.

My attorneys, managers, heirs and/or legatees shall be bound to respect my abovementioned declarations.

Done at ........................, On this ........................ Day of........................

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Signature