AGREEMENT FOR USE OF ROCK CLIMBING EQUIPMENT &
RELEASE OF LIABILITY
Name _____________________________________________ Date of Birth ________________________
Address ________________________________________________________________________________
City ________________________ State
______ Zip Code
___________ Phone _________________
Emergency Contact ______________________________________________ Phone
_________________
PLEASE READ: The form is intended to remind leaders and
participants of the seriousness of attempting climbing activities with an old
or pre-existing injury, heart condition or other condition which might be
aggravated by the event. This
information will remain valid for one year.
This document and information will remain confidential.
1.
Any pre-existing injuries (ankle, knee, neck, etc.)
that might be
aggravated by participating? YES NO
2.
Taking any current medications? YES NO
3.
Any heart problems? YES NO
4.
Do you have high blood pressure? YES NO
5.
Do you have allergies? (food,
bees, insects, medications, etc.) YES NO
6.
Do you have any physical limitations? YES NO
7.
You current level of activity at home? LOW MED HIGH
If you answered YES to any of
these questions above please discuss with the climbing staff.
In addition to please include any
information that you feel is relevant: ________________________________
________________________________________________________________________________________
PLEASE READ:
I am aware that participating in
rock climbing and artificial wall climbing carries certain risks. I choose to participate in this activity with
full knowledge of the dangers involved, and hereby agree to accept full
responsibility for my own safety. The
Center shall not be liable for any damages arising from personal injuries I
sustain in, on, or about the premises of the Center. I fully release and discharge the Center, its
affiliated entities, its employees, its contractors and its agents from any and
all claim, demands, damages, causes of action, present or future, whether they
be known, anticipated, or unanticipated, that may result from or arise out of
my use or intended use of the climbing facilities and/or equipment. Further, I agree that any equipment that I
use on the premises or borrow or rent from the Center during any climbing or
other activity, I use at my own risk.
The Center shall not be liable for any loss, damage or injury resulting
from my use of the equipment. The Center
makes no warranties regarding said equipment. The
terms of this Agreement shall also bind my family members, heirs, personal
representatives, and trustees. I
understand that this is a binding contract that supersedes any other agreement
or representations. If I wish to cancel
this contract, I must notify the Center in writing, and any such cancellation
shall only be prospective. I give my
permission to the
I am legally competent to sign
this release, or my parent or guardian has read and
signed this release.
Participant Signature: __________________________________________ Date:
__________________
If Participant is under 18 years
of age, Participant’s parent or legal guardian must also sign, assuming all of
the obligations, responsibilities, and liabilities otherwise assumed by
Participant.