Whereas Cty TNHH Xuyên Mékong and its services, among which those of Mekong-delta.com and the Bassac (here-under: TransMékong) may make some select medicine available free of charge to its passengers and participants to its services
I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , request the use of medicine from the on-board cabinet, for the use of myself or a member of my party on board (here-under: Our Party).
I am fully aware that:
I nevertheless request the use of medicine, and commit to use it only for my or my party's consumption, immediately or within the 12 hours after the end of the services or final disembarkation, whichever comes first.
I hereby:
I have read and understood this document. I am aware that by signing this document, I am waiving certain legal rights that I may have against The Releasees, and I fully agree to do so.
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Signed: . . . . . . . . . . . . . . . . Print: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . .
Date of Birth: . . . . . . . . . . .
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Date and time | Medicine | Form & dosage | Quantity |
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