Type of Instruction Lc C Kc I K
Instructor____________________
PLANET ROCK CLIMBING GYM
ACKNOWLEDGEMENT OF RISKS ASSUMPTION OF RISK AND
RESPONSIBILITY and RELEASE OF LIABILITY
WARNING: There are significant elements of risk in any adventure, sport or activity associated with a 'rock gym", climbing wall, bouldering area, and incidental weight and fitness training regimens and equipment (referred to herein as 'activity'). Although we have taken reasonable steps to provide you with appropriate equipment and/or skilled instructors so you can enjoy an activity for which you may not be skilled, we wish to remind you this activity is not without risk. Certain risks cannot be eliminated without destroying the unique character of the activity. The same elements that contribute to the unique character of the activity can be causes of loss or damage to your equipment, or accidental injury, illness, or in extreme cases, permanent trauma or death. We do not want to frighten you or reduce your enthusiasm for this activity, but we do think it is important for you to know in advance what to expect and to be informed of the inherent risks.
ACKNOWLEDGEMENT OF RISKS: I acknowledge that the following describes some, but not all of the risks: 1) Slips, trips, falls or painful crashes while using the facilities or equipment, climbing walls, bouldering areas, landing pits, work out areas, floors below climbing areas, bathroom facilities or stairs; 2) Risk associated with crossing, climbing, or down climbing; 3) Misuse of equipment or facilities, or failure of equipment; 4) My physical strength, coordination, sense of balance, and ability to follow or give directions while climbing, belaying, or working out; 5) Fatigue, chill and/or dizziness, which may diminish my/our reaction time and increase the risk of accident; 6) Abrasion from or entanglement with ropes or equipment; 7) The presence, actions or falls of other participants.
I understand the description of these risks is not complete and that other unknown or unanticipated risks may result in injury, illness or death.
EXPRESS ASSUMPTION OF RISK AND RESPONSIBILITY: In recognition of the inherent risks of the activity which I and any minor children for which I am responsible, will engage in, I confirm that I am (we are) physically and mentally capable of participating in the activity and/or using equipment. I/We participate willingly and voluntarily and I assume full responsibility for damage to or loss of my/our personal property. I also assume risk for accidents or injury caused by the negligence of the terms 'Unroped Climbing' (a.k.a.: 'Bouldering"), 'Top Rope Climbing', and 'Lead Climbing' and understand the differences between the activities. I accept that lead climbing is the most dangerous due to the hazard to both leader and follower. I agree to be 'checked out' on climbing and belaying skills prior to participation, and to follow posted rules. I acknowledge that wearing appropriate clothing and footwear are basic safety precautions, and that wearing a UIAA approved helmet may help prevent head and/or neck injuries.
I assume the risk(s) of personal injury. accidents and/or illness, including but not limited to sprains, torn muscles and/or ligaments; fractured or broken bones; eye damage; cuts, wounds, scrapes, abrasions, and/or contusions, dehydration, oxygen shortage (anoxia), exposure and/or altitude sickness; head, neck, and/or spinal injuries, insect bite or allergic reaction; shock, paralysis, and/or death.
COVENANT OF GOOD FAITH: I recognize that you, as provider of services, will operate under a covenant of good faith and fair dealing, but that you may find it necessary to refuse or terminate, the participation of any person you judge to be incapable of meeting the rigors and requirements of participating in the activity. I accept your right to take such actions for the safety of myself and/or other participants.
AUTHORIZATION: I hereby authorize any medical treatment deemed necessary in the event of any injury or illness while participating in the activity. I either have appropriate insurance or, in its absence, agree to pay all costs of rescue and/or medical services as may be incurred on my/our behalf. I agree that any film or photographs of me/us, as participants, become your property and may be used for promotional or commercial purposes.
RELEASE:
In consideration of services or property provided, I, for myself
and any minor children for which I am parent, legal guardian or
otherwise responsible, any heirs, personal representatives or
assigns, do hereby release: PLANET ROCK, INC. AND PLANET ROCK II,
INC., It's principals, directors, officers, agents, employees and
volunteers, and each and every land owner, municipal and/or
governmental agency upon whose property an activity is conducted,
from all liability and waive any claim for damage arising from any
cause whatsoever (except that which is the result of gross
negligence).
I have read and understood the foregoing acknowledgement of risk, assumption of risk and responsibility, and release of liability. I understand that by signing this form I may be waiving valuable legal rights.
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Participant's Name (Printed)
Signature
Today's Date ___/____/____
Email: ____________________________
Phone: (_____)______-_______ Work: (_____)______-_______ Birthdate: / _ / _ Male Female (Please Circle One)
Address:_________________________________________________________________________________________________________________
Street
City
State
Country Zip
In an emergency, notify: ________________________________ Phone: (______)______-________
If the participant is under 18, the Parent or Legal Guardian must also sign:__________________________
RULES AND REGULATIONS
1. All individuals entering the gym must first sign the appropriate
waivers or log-in books and present pass before being allowed to
climb.
2. Upon the first visit, everyone must either demonstrate the ability to "tie in" with a "figure-8" knot, belay, and use the appropriate safety commands or, the participant will be required to go through a training course which will show them these basic requirements for both top roping, and leading.
3. No one under the influence of drugs or alcohol will be admitted. Accordingly, by signing the log-in book the participant is stating that he/she is not under the influence of such substances.
4. You must have a valid I.D. to prove your age. All children age 15 and under must have a parent or guardian with them at all times. Also, all children age 12 and under must wear a helmet when climbing. All participants with a history of head trauma must wear a helmet. If you have a history of head trauma or medical problem, you must disclose this to a gym representative before you participate. All belayers must be at least 14 years of age.
5. All participants are expected to warm up and stretch prior to climbing to reduce the risk of injury.
6. Participants can only climb on designated climbing surfaces. Anyone found climbing on building structure pipes, ladders or wall space not designated as a climbing zone will be asked to leave the premises.
7. All participants whose feet are 5 feet or higher above the ground must be belayed except in designated bouldering areas where they must be spotted. It is the responsibility of the participant to choose a safe partner for belaying or spotting. Also, the participants must be aware to not climb below or across the path of another participant.
8. Only approved, manufactured climbing harnesses, belay devices and gear are allowed. If the participant's equipment does not meet these requirements or is deemed unsafe, he/she will have to rent or acquire the correct equipment.
9. All participants must tie directly to their harnesses rather than to a carabiner to reduce the risk of equipment failure.
10. All belays are encouraged to attach their harnesses to a designated ground anchor as a back up only.
11. Any flagrant disregard of these rules or unsafe actions shall result in immediate loss of gym privileges.
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__________________________________
Participant's Name (please print)
Parent/Guardian
Name (please print)
_________________________________
__________________________________
Participant's Signature
Parent/Guardian Signature
HELMET WAIVER
I, the undersigned, recognize and acknowledge the dangers inherent
with climbing, including the risk of serious injury or death by
falling or someone or something falling that may come in contact
with me. I am further aware that use of a protective helmet can
reduce the risk of a head injury or brain damage in the event of an
accident. Against the advice of Planet Rock and its insurance
company, I am refusing to use this important safety equipment.
Note: This waiver cannot be used for children age 12 and under.
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Participant's Name (please print)
Witness or Parent/Guardian Name (please print)
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Participant's Signature
Witness or Parent/Guardian Signature