I, (ID No. ), parent / guardian of hereby consent to receiving breastmilk as provided by the South African Breastmilk Reserve having been informed of the material risks and benefits thereof. Healthy breastmilk has been donated in good faith for the feeding of the abovementioned infant.

I shall not claim or take legal action against the South African Breastmilk Reserve, an Association incorporated under the terms of Section 21 of the Companies Act, 1973, its servants, employees, representatives or agents; or the attending doctors or any of the aforementioned persons' insurers (all of whom will hereinafter be referred to as "The Releasees").

I hold The Releasees free from any liabilities of whatsoever nature: Of any harm, loss, consequential loss, damage, death or injury of whatsoever nature that either I or the abovementioned infant may suffer, arising from the administration or supply of breastmilk by the Releasees or the contracting of medical pathologies there from and howsoever such harm, consequential loss, damage, injury or death may occur.

I confirm that the way in which the breastmilk will be used after the date of release, is not the responsibility of the Releasees.

I acknowledge that I am aware of the cost of the abovementioned breastmilk and that payment will be made accordingly.