WAIVER OF LIABILITY AND INDEMNITY

in favour of Sullivan Healthcare Limited operating as

CHOICE SELF-DIRECTED HEALTHCARE (“Choice”)

I, the undersigned, understand, acknowledge and agree that:

1. participation in medical treatment and/or surgical procedures involves serious inherent risk(s);

2. there are additional serious risks inherent in travel and in participation in medical treatment and/or surgical procedures in jurisdictions outside of Canada ;

3. Choice has provided and will continue to provide services to assist me to:

a) consult with medical doctors and surgeons in Cuba ;

b) arrange, pay for, attend and undergo medical treatment and/or surgical procedures in Cuba ; and

c) make travel arrangements to, from and within Cuba ;

4. in so doing, Choice has not at any time:

a) provided medical advice or recommendations to me;

b) assessed my fitness for purposes of traveling or undergoing any medical treatment and/or surgical procedures;

c) approved or endorsed any medical professional, service provider, treatment or procedure;

5. Choice does not employ medical professionals or any other personnel who may be relied upon to give medical advice, assessments, recommendations or endorsements at any time during my medical travel;

6. my travel to Cuba and my medical treatment and/or surgery in Cuba are undertaken solely at my own risk;

THEREFORE, and in any event, I hereby waive, remise, release and forever discharge Choice and Sullivan Healthcare Limited, and its officers, directors, shareholders, servants, employees and agents, and the successors and assigns thereof (herein individually and collectively called “Choice”), of and from every and any claim of any nature or kind whatsoever that I have, can, shall or may hereafter have, including, without limitation, claims, demands, damages, actions, causes of actions, costs and expenses arising out of or relating to my death, injury, loss or damage (such as disability, loss of capacity, pain and suffering, medical or surgical complication), howsoever caused, arising directly or indirectly out of or in connection with my travel to, from or within Cuba and/or any medical treatment and/or surgical procedures undergone by me in Cuba;

AND I agree to save harmless and indemnify Choice from and against every and any claim of any nature or kind whatsoever that any third party can, shall or may hereafter have against Choice, including without limitation claims, demands, damages, actions, causes of actions, costs and expenses arising out of or relating to my death, injury, loss or damage (such as disability, loss of capacity, pain and suffering, medical or surgical complication), howsoever caused, arising directly or indirectly out of or in connection with my travel to, from or within Cuba and/or any medical treatment and/or surgical procedures undergone by me in Cuba.

This Waiver of Liability and Indemnity shall be and is binding upon me, my heirs, executors, administrators, successors and assigns.

By signing this document, I confirm that I have read and understand it.

PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING AS IT CONTAINS PROVISIONS WHICH SIGNIFICANTLY AFFECT YOUR LEGAL RIGHTS AND IMPOSES RESPONSIBILITIES UPON YOU.

SIGNED on __________, 200__ at the City/Town of ____________, in the Province of ______________________.